College/University Internship or Student Teaching - Background Check Application

First name*

Last name*

Email address*

Location *

Phone number*

Resume

Who referred you to this position? Enter their first and last name here.

What’s your citizenship / employment eligibility?*

Have you ever been convicted of a felony?*

If “Yes”, you have been convicted of a felony, please explain the circumstances around the conviction:*

How many hours are you able to give weekly?

“I, the undersigned applicant, do hereby certify that
the information provided by me for the purpose of
employment is true and complete to the best of my
knowledge. I understand the results of this verification
process will be used to determine my
eligibility to be considered for election or appointment to the LSC Board of Directors. I further understand that any
false, misleading or incomplete answers or
statements or implications made by me in connection
with my application, or other required documents, or
the failure to disclose any relevant information, shall
result in the denial of employment or justification for
discharge if discovered at a later date.”*

Gender

Race/Ethnicity

Human Check*