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AUC-R l Atlanta Urban .Corps ENROLL MENT IN application FO R OFFICE USE ON L Y INTERN NO. PREVIOUSLY EMPLOYED IN URBAN CORPS . A V AILABLE co TIGE D D D D SUMMER PRO GRAM ACAD EMIC YEAR FUL L TI ME D PAR T T IME NO IF YES, DAT E: PLEASE PRINT NAME ...J < z (Cit y & St ate ) PER MAN ENT ADDRE SS 0 V, a:: w a. (City & State) ADDRES S DUR IN G I NTE RN SHIP DATE OF BIRTH < z -0I- Fr eshman D Soph omore < u FOREIGN LANGUAGE (S) 0 1.
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DEPE N DE NTS
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SCH OLAST IC HONOR S
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TELEP H ON E (Are a Code)
MAJOR FIE L D OF ST UD Y
ACADE MIC LE V EL (Sum me r Appli c an ts U se Foll L evel )
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MARITAL ST ATUS
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I f you ho ve parti c i pa te d i n Urban Cor ps c irc l e l ett er of rr eviously
li st ed " P ost Em p l oyment" posit i on to wh ic h you would i ke to reto m . (if an y )
(Circl e On e)
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PREFEREN C E ( Li st i n order o f in teres t - See Ind ex for po si ti on tit l e and no . )
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AVAIL A BLE WEE K ENDS
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RELEVANT COURSE(S) - TITLE (In As signment Area)
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FUTURE CARE E R PLANS
If Addi t ional Space is Required Attach a B l ank Sheet for E xpans ion. Plac e Your Nome and Co ll ege At top of Eoch .
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No
�NAME
(Last)
(First)
(Middle In i tial)
RELATIONSHIP
IN
EMERGENCY
CONTACT
STREET ADDRESS
(City & State)
(Zip Cade)
TELEPHONE (Area Code)
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The Minimum Amount I must earn this summer to rema i n in school is$
My Parents Total Income is $
I would
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would not
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consider working i n the Atlanta Urban Corps as a volunteer .
STUDENT CERTIFICATION
I, the above named applicant, hereby certify that I am enrolled, or accepted for enrollment, as a full-time
student at the institution named. As an ATLANTA URBAN CORPS intern I understand that as an employee of the
agency for whom I work I will be expected to perform my assignment in a mature and responsible manner, and wil I
comply with the requirements of the assignment and the instructions of my supervisor. I understand that I may be
removed from my assignment and from the Atlanta Urban Corps if I do not perform my work in o proper manner or
otherwise do not comply w_ith the regulations of the Atlanta Urban Corps.
(Signature)
(Date)
COLL EGE CERTIFICATION
I, the duly authorized College Work-Study Coordinator of the institution named in this application, hereby
authorize the employment of the above named applicant by the Atlanta Urban Corps under the terms of the Agreement entered into between said institution and the Atlanta Urban Corps tor the conduct of a work-study program
under the Federal College Work - Study Program, as pro v ided by the Economic Opportunity Act of 1964, as amended.
I hereby certify that said institution will provide that portion of the applicant's compensation as provided
in said agreement, and that the applicant has been informed of his obligations and limitations under the Work Study program .
(T i tl e )
(Authoriz e d Signature)
(Coll e ge )
(Dat e)
INSTRUCTIONS (Read Carefully)
Complete the top section of the application form . Check "Summer Program only when application is made
for the summer period. Check "Academic Year Program " for the period from the middle of September th rough the
middle of June.
Check either " Part-Till]e " or "Full-Time " in accordance with the Federal regulations regarding the WorkStudy Program . For periods during which you w ill not be attending clas·ses, you may work full time .
PERSONAL SECTION : "Address during internship" refers to the address where y ou can be contact e d during th e
period of your internship . Correspondence during the internship period will be mailed to this address. You must include Zip Code for each address .
EDUCATIONAL SECTION : "College " re fers to the inst i tution which certifies your application.
ting or transferr i ng schools, indicate y our ne w college.
If you are gradua-
PAST EMPLOYMENT SECTION: Include all pre v ious employment. Include in the section any pr i or Urban Corps inte rnships .
WORK ASSIGNMENT SECTION: Sel ec t fou r cat egories of i ntere st from th e Inde x of Assignm ent C ategories, and
list them in the order of pre f erence.
CERTIFICA TIO N S: Pl e a se r e ad certi f icat i ons c arefully .
AS SI GNM E N T CODE NO .
RE ASS IGNE D
TR A NS F .
F OR OFFI C E U S E ONL Y
Da te Re cei ve d
Ch e c ked By
Date Payr o ll e d
Di stri b ut io n Code
P a y Ra t e
Wit hdr aw n
.
In co m p le t e
RETURNED
TO
( Do t e )
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Coll e ge
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Stu d e n t
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