Internship/Volunteer Program Application Form

Date*
MM slash DD slash YYYY
Personal History
Name*
First Middle Last
Date of Birth*
Month
Day
Year
Email (Please provide a personal email, not a school email)*
Address*
Street Address City State ZIP Code
List all other names (Maiden name/Nicknames):
If you have ever changed your name, give date, place, and reason. If no, please response no.*
Are you a resident of MA?*
- Yes
- No
If not, what state?*
Are you a citizen of the United States?*
- Yes
- No
If naturalized, give place of naturalization and naturalization number:*
Are you legally authorized to work in the United States?*
- Yes
- No
Cell Phone Number*
Residence Phone Number
Have you ever submitted an application to work for the Worcester District Attorney's Office?*
- Yes
- No
If yes, give date:*
Former Addresses*
From (Month/Year) To (Month/Year) Apartment no. Street Address City State Zip

List chronologically all of your residences in the past 10 years and dates of residency. (Include addresses while attending school if away from home and all military addresses including any off military base.) Example: 1 Main St., Worcester, MA 01604 | From 01/2010 - 10/2015
Resume*
Drop files here or

Max. file size: 20 MB.
Cover Letter*
Drop files here or

Max. file size: 20 MB.
Education
Select highest school grade completed:*
- 9
- 10
- 11
- 12
Dates Attended*
From To
Name of last school attended:*
Address of last school attended:*
Did you graduate?*
- Yes
- No
College, Law School, and Other Education
Name of School Major and/or Course of Study Dates Attended From Dates Attended To (Or Expected Grad Date) Type of Diploma or Degree Earned If no degree, # of credits
Were you ever dismissed from a school, or was any disciplinary action ever taken against you during your scholastic career*
- Yes
- No
List*
School Date Type of Action
Do you speak any foreign languages?*
- Yes
- No
If so, please provide:*
Employment
Current Employment*
Name of Employer Address of Employer Date Employment Began Position/Job Description Name of Supervisor
Previous Employment*
Name of Employer Address of Employer Date Employment Began Type of Employment (Part-time, Seasonal, etc.) Position Job Description

List chronologically all employment, including summer and part-time employment, or internship while attending school. Begin with present employer. If not employed/previously employed, put N/A.
References (3 Required, click the (+) icon for additional rows)*
Name Address Number of Years Acquainted Occupation Telephone Number/Email

Give three references (not relatives) who are responsible adults of reputable standing in their communities, preferably those who have known you for at least five years.
Court Record
Have you ever pled guilty, nolo contendere, no contest, or been convicted of any misdemeanor or felony offense (regardless of whether fine or penalty imposed) including any cases which were subsequently expunged?*
- Yes
- No
Are there any criminal charges pending against you?*
- Yes
- No
Please give details, please note this information does not necessarily disqualify you.*
Date Place and Department Charge Final Disposition Details
Please give details, please note this information does not necessarily disqualify you.*
Date Place and Department Charge Final Disposition Details
To the best of your knowledge has any member of your immediate family ever pled guilty, nolo contendere, no contest, or been convicted of any misdemeanor or felony offense (regardless of whether fine or penalty imposed) or are there any criminal charges pending against any member of your immediate family?*
- Yes
- No
Have you ever sat on or been selected to sit as a jury member on a criminal matter within Worcester County or Massachusetts?*
- Yes
- No
Please give details, please note this information does not necessarily disqualify you.*
Name Relation Date Place Charge Final Disposition Details
Have you ever been a defendant in litigation related to your employment? i.e. malpractice actions, civil rights, etc.*
- Yes
- No
If yes, please provide details:*
Do you have any claims pending against the State, its agencies, or employees in any forum?*
- Yes
- No
If yes, please provide details:*
Military Record
Have you ever served on active duty in the Armed Forces of the U.S.?*
- Yes
- No
Date Commissioned, if applicable:
MM slash DD slash YYYY
Serial Number:
Branch of Military Service
Member of Reserves?
- Yes
- No
Date of Active Duty (Month/ Day/ Year)
From To
Type of Discharge:
Basis of Discharge
Relatives
All applicants must give complete information concerning their relatives. If you have been married more than once, give the requested information concerning each former husband or wife. Even though a relative is deceased, give all the information requested, and indicate last residence, year of death. Include stepbrothers and sisters, half brothers and sisters. If you are engaged to be married or contemplating marriage in the future, complete information regarding your future husband or wife, and clearly show that such a relationship is a future one.
Marital Status*
- Single
- Married
- Separated
- Divorced
- Widowed
Place of Marriage:
Date of Marriage:
Number of Children:
Place of Divorce/Legal Separation:
Court:
Date:
Final Disposition:
List all immediate family members (mother, father, guardians, siblings) by complete name including middle (no initials), complete address:*
Name Relation Address Birth Date Occupation - Name and Address of Place of Employment
Personal Questionnaire
List any special skills or training that you have acquired that would be beneficial to the Worcester District Attorney's Office, including membership in professional organizations. If none, write N/A.*
List any awards, honors, citations, positions held in school organizations. If none, write N/A.*
List hobbies and recreational interests, including clubs and organizations (you need not include political organizations or associations). If none, write N/A.*
List any public service or community activities that you are or have been involved in. If none, write N/A.*
Explain in your own words why you are interested in an internship/volunteer placement with the Worcester District Attorney's Office:*
What internship session are you interested in?*
- Spring
- Summer
- Fall
The information solicited in this application for internship/volunteering is necessary to complete your background investigation. In order for the Worcester District Attorney's Office to have sufficient information to complete this investigation, you must complete this application in its entirety. The information solicited herein and the results of the investigation that follows will be used to determine your sustainability for employment with the Worcester District Attorney's Office. You should be aware that willfully making a false statement or concealing a material fact in your application for employment will be the basis for dismissal from the Worcester District Attorney's Office. I am aware that willfully withholding information or making false statements on this application will be the basis for dismissal from the selection process, or from the Worcester District Attorney's Office, if later discovered. I agree to to these conditions and I hereby certify that all statements made by me on this application are true and complete, to the best of my knowledge.
Electronic Signature:*
Untitled

From (Month/Year)	To (Month/Year)	Apartment no.	Street Address	City	State	Zip

From	To

Name of School	Major and/or Course of Study	Dates Attended From	Dates Attended To (Or Expected Grad Date)	Type of Diploma or Degree Earned	If no degree, # of credits

School	Date	Type of Action

Internship/Volunteer Program Application Form

Internship/Volunteer Program Application Form

Personal History

Education

Employment

Court Record

Military Record

Relatives

Personal Questionnaire

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