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2. 
3. Therapeutic Recreation Internship Application
5. Full Name*
7. Mailing Address*
9. City*
10. State*
11. Zip Code*
13. Telephone (primary)*
14. Telephone (alternative)*
16. Email Address*
18. Are you legally eligible to work in the United States?*

    1. Yes
    2. No
19. If you are under 18 years of age, can you provide proof of eligibility to work?*

    1. Yes
    2. No
21. If hired, are you able to perform the essential job functions of the job you are applying for, with reasonable accommodation? *

    1. Yes
    2. No
25. What position are you applying for?*
27. Which of the following are you available to work? *

    Select all that apply

    1. Full Time
    2. Part Time
    3. Evenings
    4. Weekends
    5. Temporary/Seasonal
28. Are you able to work overtime on weekends, evenings, and holidays if necessary?*

    1. Yes
    2. No
30. How did you hear about the position?*
31. Have you ever been an employee of the Town of Burlington? *

    1. Yes
    2. No
33. If you have been employed by the Town of Burlington, please give dates and tell us for which department.
35. Please list all schools you have attended, the years you attended, and any degree earned. (Include High School, College, Graduate, and Vocational Schools) *
37. Describe any specialized training, coursework, or apprenticeships.*
39. List professional, trade, business, or civic activities and offices held.*
41. Please list any skills you have that are relevant to the position you are applying for. (This may include use of technology or foreign languages)*
43. Do you have a valid driver's license?*

    1. Yes
    2. No
44. What class of license do you possess? Check all that apply, if any.*

    Select all that apply

    1. Class D
    2. CDL A
    3. CDL B
    4. CDL C
46. For any driver's license possessed, what is the date of expiration?*
47. Have you ever had your license or driving privileges revoked, suspended, or placed on probation?*

    1. Yes
    2. No
49. If you have had your license or driving privileges revoked, please explain. Include when, where and what action was taken.*
51. Do you have any friends and/or relatives that work for the Town of Burlington? If so, please let us know their name and relationship to you.*

     (Up to two names)

55. Please list 3 professional and/or business references only. (Include persons name, company name, phone number, and their relationship to you).*

    Please list all three here.

57. Do you have employment or volunteer experience to add?*

    1. Yes
    2. No
58. Employment/Volunteer Experience Company Names*

    Please list them here.

60. Employment/Volunteer Experience Company Addresses*

    Please list them here.

62. Supervisor's Names and Telephone Numbers*

    Please list them here.

64. May we contact these employers?*

    1. Yes
    2. No
65. What dates were you employed from, and how many hours per week did you work?*

    Please list from each employment/volunteer opportunity.

67. Description of Duties:*

    Please list separate descriptions of each employment/volunteer opportunities

69. Reason for leaving or seeking other employment*
73. Do you have another employment or volunteer experience to add?*

    1. Yes
    2. No
75. If yes, explain here.
Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit Submit and Print

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