ࡱ> lnk` USbjbj Z vvvv4B ' ' ' 'lv'B9())))*5,-t2222+269$:h2=99]-**--99vv))9-/-/-/-vl))2-/-2-/-//,/)( N '-/0909/=-=/=/T---/-----9999-/---9----BBB&BBB&BBBvvvvvv9 Department of Administrative Services  Human Resources Enterprise (DAS-HRE) Internship Development Program Application Name: FORMTEXT       FORMTEXT       FORMTEXT   Social Security #: FORMTEXT      LastFirstMIPresent Address: FORMTEXT      ( FORMTEXT    ) FORMTEXT      phonePermanent Address: FORMTEXT      ( FORMTEXT    ) FORMTEXT      phone Education College/University: FORMTEXT      Major: FORMTEXT      Degree Program (check one): FORMCHECKBOX A.A.  FORMCHECKBOX B.A.  FORMCHECKBOX M.A.  FORMCHECKBOX PhD.Completion Date: FORMTEXT       Coursework related to internship: FORMTEXT       References  FORMTEXT        Internship Instructions Submit this completed form plus a letter from your counselor or advisor stating 1) your major area of study, and 2) if this internship is for credit towards a program or needed for work experience. If for credit, outline the goals and objectives for the internship. This internship is for credit towards a degree program: Yes  FORMCHECKBOX  No  FORMCHECKBOX  For Pay: Yes  FORMCHECKBOX  No  FORMCHECKBOX  This application is valid until your graduation date or until you notify DAS-HRE asking the application be withdrawn. Date available to begin internship: FORMTEXT      Applicant Signature Date of application: FORMTEXT       EEO/AA Data Survey Iowa state government is committed to the principles of Equal Employment Opportunity and Affirmative Action. To evaluate the success of our EEO/AA program, we must collect information about job applicants. Please share some information about yourself to assist us in doing this. This information is used only for program evaluations and reporting requirements, and is removed before your application is processed. PLEASE WRITE YOUR NUMBERED RESPONSES TO ITEMS A THROUGH C IN THE CORRESPONDING BOXES. A B C  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN A. What sex are you? 0. Male 1. Female B. Of which racial/ethnic group do you consider yourself a member? 0. White: Origins in any of the original peoples of Europe, North Africa, or the Middle East. 1. Black: Origins in any of the black racial groups. 2. Asian/Pacific Islander: Origins in the original peoples of the Far East, Southeast Asia, Indian Subcontinent, or the Pacific Islands.       $ & ( * > @ B L N P R f ĵwaKa+jhhCJOJQJU^J*jhCJOJQJU^JmHnHu+jhhCJOJQJU^JhCJOJQJ^JjhCJOJQJU^JhOCJOJQJ^JhUhUCJOJQJ^JhUhLVCJOJQJ^JhUhLVCJOJQJ^JhUhLVOJQJ^JhUhLV5CJOJQJ^J ( P r qqq$$Ifa$gdUl$$Ifa$l$a$Kkd$$IfT$&~&   4 aWp T  $If $x$Ifa$ PSTSf h j n p ٴv`NGN8NhU6CJOJQJ^JaJ hUhU#hUhU6CJOJQJ^JaJ*jh)aCJOJQJU^JmHnHu+jh)ahCJOJQJU^Jh)aCJOJQJ^Jjh)aCJOJQJU^JhOCJOJQJ^JhUhUCJOJQJ^J*jhCJOJQJU^JmHnHujhCJOJQJU^J+jphhCJOJQJU^J _L8$@&IfgdUl$$Ifa$lkdX$$Iflֈ d&< E/ t44 la  8kd_$$Iflֈ d&< E/ t44 la$$Ifa$l$$Ifa$gdUl     " , . 2 4 6 J L N T V X Z \ p r t ~ ɳ՝{՝Ցe՝S#hUha6CJOJQJ^JaJ+jJh)ahCJOJQJU^J+jh)ahCJOJQJU^JhaCJOJQJ^J*jh)aCJOJQJU^JmHnHu+jbh)ahCJOJQJU^Jh)aCJOJQJ^Jjh)aCJOJQJU^JhOCJOJQJ^JhUhaCJOJQJ^J 0 2 Z _kd$$Iflr{&1?@ t44 la$$Ifa$l        ( * , 6 ϳ{oY{oϳC{+jhh)ahCJOJQJU^J+jh)ahCJOJQJU^JhaCJOJQJ^J*jh)aCJOJQJU^JmHnHu+jh)ahCJOJQJU^Jh)aCJOJQJ^Jjh)aCJOJQJU^JhOCJOJQJ^JhUhaCJOJQJ^J#hUha6CJOJQJ^JaJha6CJOJQJ^JaJ  : taaaaa$$Ifa$lkd$$Iflr{&1?@ t44 la6 8 < R T f h j x οvj^H2v*jh)aCJOJQJU^JmHnHu+j h)ahCJOJQJU^Jh)aCJOJQJ^JhOCJOJQJ^JhaCJOJQJ^JhahaCJOJQJ^JhDhLVCJOJQJ^JhUhLVCJOJQJ^JhUhLV5CJOJQJ^Jh)ahUCJ OJQJ^J#hUha6CJOJQJ^JaJhUhaCJOJQJ^Jjh)aCJOJQJU^J: < > @ B N P r_____$$Ifa$lkd$$Iflr&\?@ t44 laP R T h j tooo\\\\$$Ifa$l$a$kd $$Iflr&\?@ t44 la 0 2 4 6 R T V d f ɳ՝偑kU+j hahLVCJOJQJU^J+jP hahLVCJOJQJU^JjhaCJOJQJU^JhaCJOJQJ^J*jh)aCJOJQJU^JmHnHu+j$ h)ahCJOJQJU^Jh)aCJOJQJ^Jjh)aCJOJQJU^JhahaCJOJQJ^JhOCJOJQJ^J rrrr$$Ifa$lzkd $$Ifl\Pz%*~  t44 la 4  : rrrr$$Ifa$lzkdu $$Iflp\Pz%*~  t44 la     ( * , 6 8 < > ͷͨ͜jTEhDhaCJOJQJ^J*jh)aCJOJQJU^JmHnHu+j h)ahCJOJQJU^Jh)aCJOJQJ^Jjh)aCJOJQJU^JhOCJOJQJ^JhahaCJOJQJ^J+jhahLVCJOJQJU^JhaCJOJQJ^JjhaCJOJQJU^J+j8hahLVCJOJQJU^J: < > mm$$Ifa$l$a$zkd$$Ifl\ % 4 b t44 la> D ~ ʺsfYG:h)a>*CJOJQJ^J"jh)a>*CJOJQJU^Jh)ahLVOJQJ^Jh)ah)aOJQJ^JhDhaCJOJQJ^J*jh)aCJOJQJU^JmHnHu+jch)ahCJOJQJU^Jh)aCJOJQJ^Jjh)aCJOJQJU^JhkhaCJOJQJ^JhOCJOJQJ^JhkCJOJQJ^JhkhkCJOJQJ^J ?Bkd$$IflR&& t&644 la$ %dh$Ifa$gdDlgd)a$a$Ukd$$Ifl0 &p  t644 la [\]kֲֿzn_S@%jhUhLVCJOJQJU^JhCJOJQJ^JhUh)aCJOJQJ^JhLVCJOJQJ^JhUhLVOJQJ^JhUhLVCJOJQJ^Jh)aCJOJQJ^Jh)ah)a>*CJOJQJ^JhD>*CJOJQJ^J-jh)a>*CJOJQJU^JmHnHu"jh)a>*CJOJQJU^J.j}h)ah>*CJOJQJU^J z|$$Ifa$lgd$a$ klmoqstuz|ǻǻǥǙǻǃǻǻmbVhLVCJOJQJ^JhhLVCJaJ+jhUhLVCJOJQJU^J+j[hUhLVCJOJQJU^JhOCJOJQJ^J+jhUhLVCJOJQJU^JhCJOJQJ^JhUhLVCJOJQJ^J%jhUhLVCJOJQJU^J+jshUhLVCJOJQJU^J @BDFZ\^hjnpl﫟zj[K<hUhLVCJOJQJ^JhUhLV5CJOJQJ^JhUhLVCJOJQJ^JhUhLV5CJOJQJ^JhhLVCJOJQJ^J+jh)ahCJOJQJU^JhOCJOJQJ^JhCJOJQJ^J*jh)aCJOJQJU^JmHnHu+jCh)ahCJOJQJU^Jh)aCJOJQJ^Jjh)aCJOJQJU^JDl}gg$$Ifa$gdl$a$gdykd$$Ifl\N ^&   t644 lalnpl$$Ifa$gd{'>lgdO $xa$gdD$a$Skd $$Ifl0I  t644 la ,?ëџÇџoџcQHhUhLV^J"hhLV5CJOJQJ\^JhDCJOJQJ^J/jhDhDCJ OJQJU^JaJ /j5hDhDCJ OJQJU^JaJ h{'>CJOJQJ^J/jhDhDCJ OJQJU^JaJ hDCJ OJQJ^JaJ #jhDCJ OJQJU^JaJ hOh hOhLVhUhLVCJOJQJ^J,4>?PQpkkkkikkkkkk$a$kda$$Iflvr N \ P t644 la( 3. Native American/Alaskan Native: Origins in any of the original peoples of North America who maintain cultural identification through tribal affiliation or community recognition. 4. Latino: Persons of Mexican, Puerto Rican, Cuban, Central regardless of race. 5. Declined to respond. C. Do you have a disability that is a physical or mental impairment that substantially limits one or more major life activities; do you have a record of such an impairment; or are you regarded as having such an impairment? 0. No 1. Yes 2. Declined to respond. 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