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AUC-RI1
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Atlanta Urban Corps application
ENROLLMENT IN AVAILABLE PREVIOUSLY EMPLOYED IN URBAN CORPS. FOR OFFICE USE ONLY
COLLEGE | INTERN NO.
(J SUMMER PROGRAM ( FULL TIME
(0 ACADEMIC YEAR (J PART TIME CL] NO IF YES, DATE:
PLEASE PRINT
NAME (Last) (First) (Middle)
# PERMANENT ADDRESS (City & State) (Zip Code) TELEPHONE (Area Code)
5
a | ADDRESS DURING INTERNSHIP (City & State) (Zip Code) TELEPHONE (Area Code)
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DATE OF BIRTH SOCIAL SECURITY NO. MARITAL STATUS DEPENDENTS
C1 Single (-) Married
COLLEGE MAJOR FIELD OF STUDY DEG. SOUGHT |DEGREE DATE
z ACADEMIC LEVEL (Summer Applicants Use Fall Level) GRADUATE STUDENT [J
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e (CL) Freshman ([) Sophomore () Junior () Senior Under Grad. Major:
< | FOREIGN LANGUAGE(S)
S (CL) Speak (] Speak
_ 1. (J Read [7] Write 2. C) Read (] Write
AVERAGE (Circle) SCHOLASTIC HONORS
AB Cc OD
EMPLOYER DATE SALARY
A From To
is JOB TITLE AND DUTIES
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=F EMPLOYER DATE SALARY
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=. JOB TITLE AND DUTIES
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ae EMPLOYER DATE SALARY
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ClJOB TITLE AND DUTIES
If you have participated in Urban Corps circle letter of previously (Circle One)
listed ‘‘Past Employment’’position to which you would like to return. (if any) A B ¢
PREFERENCE (List in order of interest — See Index for position title and no.)
TITLE CODE NO.
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NEIGHBORHOOD PREFERENCE AVAILABLE EVENINGS AVAILABLE WEEKENDS
Cl Yes C1 No O Yes (_] No
; RELEVANT COURSE(S) — TITLE (In Assignment Area)
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\4 SPECIAL SKILLS (Include machines you can operate)
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@ | HOBBIES
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2 [EXTRA CURRICULAR ACTIVITIES
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% | FUTURE CAREER PLANS
If Additional Space is Required Attach a Blank Sheet for Expansion. Place Your Name and College At top of Each.
NAME (Last) 5 (First) (Middle Initial) RELATIONSHIP
IN
EMERGENCY
CONTACT STREET ADDRESS (City & State) (Zip Code) TELEPHONE (Area Code)
The Minimum Amount | must earn this summer to remain in school is $
My Parents Total Income is $
FINANCIAL
| would []) wouldnot [] consider working in the Atlanta Urban Corps as a volunteer.
STUDENT CERTIFICATION
|, the above named applicant, hereby certify that | am enrolled, or accepted for enrollment, as a full-time
student at the institution named. As on ATLANTA URBAN CORPS intern | understand that as an employee of the
agency for whom | work | will be expected to perform my assignment in a mature and responsible manner, and will
comply with the requirements of the assignment and the instructions of my supervisor. | understand that | may be
removed from my assignment and from the Atlanta Urban Corps if | do mot perform my work in a proper manner or
otherwise do not comply with the regulations of the Atlanta Urban Corps,
(Signature) (Date)
COLL EGE CERTIFICATION
|, 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 Urbon Corps under the terms of the Agree-
ment entered into between said institution and the Atlanta Urban Corps for the conduct of a work-study program
under the Federal College Work-Study Program, as provided by the Economic Opportunity Act of 1964, as amended.
| 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.
(Authorized Signature) (Title) (College) (Date)
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 through the
middle of June.
Check either ‘‘Part-Time’’ or ‘‘Full-Time’’ in accordance with the Federal regulations regarding the Work-
Study Program. For periods during which you will not be attending classes, you may work full time.
PERSONAL SECTION: “Address during internship” refers to the address where you can be contacted during the
period of your internship. Correspondence during the internship period will be mailed to this address. You must in-
clude Zip Code for each address.
EDUCATIONAL SECTION: ‘‘College’’ refers to the institution which certifies your application. If you are gradua-
ting or transferring schools, indicate your new college.
PAST EMPLOYMENT SECTION: Include all previous employment. Includein the section any prior Urban Corps intern—
ships.
WORK ASSIGNMENT SECTION: Select four categories of interest from the Index of Assignment Categories, and
list them in the order of preference.
CERTIFICATIONS: Please read certifications carefully.
FOR O
ASSIGNMENT CODE NO. REASSIGNED| TRANSF.| Date Received Checked By Date Payrolled
Distribution Code Pay Rate ithdrawn
Incomplete
RETURNED TO [j College ([] Student