FDF
Apply.pdf
130
Elm
Street
Old Saybrook, CT
projectcourageworks.com
860-388-9656
Employment/ Internship Application
It is the policy of Project Courage to provide reasonable accommodations to qualified individuals with a
disability who are either applicants for employment or are current employees.
Should you require any
assistance or reasonable accommodation to complete this application or participate in interviews,
please make a note on the application or notify the interviewer.
Date ___________
PERSONAL INFORMATION
Name:
Are You 18 years of age or Older?
Yes
No
Address:
Street
City
State
Zi
Phone Number :
Email Address:
WORK EXPERIENCE
Begin With Most Recent First
Employer:
Address:
Telephone Number:
Position:
Full or Part Time?
Dates of Employment:
Duties
Reason for Leaving:
Employer:
Address:
Telephone Number:
Position:
Full or Part Time?
Dates of Employment:
Duties
Reason for Leaving:
Employer:
Address:
Telephone Number:
Position:
Full or Part Time?
Dates of Employment:
Duties
Reason for Leaving:
Employer:
Address:
Telephone Number:
Position:
Full or Part Time?
Dates of Employment:
Duties
Reason for Leaving:
INTERN/VOLUNTEER EXPERIENCES
AGENCY NAME
PAID? INTERN OR VOLUNTEER?
130
Elm
Street
Old Saybrook, CT
projectcourageworks.com
860-388-9656
EDUCATION/CERTIFICATIONS
Education Level
Name and Location of School
# Years
Attended
Degree
Completed?
Major/Minor
High School
College
Grad School
Other Education /
Special Training
Certifications Held
IF INTERN: PRACTICUM/FIELD INSTRUCTOR
Name
University / College
Phone Number or Email
POSITION DESIRED/APPLYING FOR:
Name
Desired Salary:
Part Time or Full?
Emergency Contact Information
Relationship:
Name:
Phone:
BACKGROUND VERIFICATION
Has your driver’s license ever been suspended or revoked in any state?
Yes
No
If you are certified or licensed to provide mental health and/or substance abuse services has your
license or certification ever been suspended or revoked in the state of Connecticut or any other state?
Yes
No
Do you have any physical limitations or are you under any course of treatment which might limit your
ability to perform certain types of work?
Yes
No
If yes to any of the
above, please explain:
130 Elm
Street
Old Saybrook, CT
projectcourageworks.com
860-388-9656
PROFESSIONAL REFERENCES (non-family members)
Name:
Phone:
Address:
Email:
Name:
Phone:
Address:
Email:
PERSONAL REFERENCES (family members and friends)
Name:
Phone:
Address:
Email:
Name:
Phone:
Address:
Email:
I certify the above information contained in this application is true correct, and complete.
I understand
that, if employed, false statements reported on this application may be considered sufficient cause for
dismissal/termination.
Signature of Applicant:________________________________________
Date:___________