Fillable Commonwealth of Massachusetts Department of Correction - Student Internship Application

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Commonwealth of Massachusetts Department of Correction - Student Internship Application

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The Commonwealth of Massachusetts Department of Correction - Student Internship Application form is 7 pages long and contains:

  • 4 signatures
  • 18 check-boxes
  • 101 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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1
Commonwealth of Massachusetts
Department of Correction
Student Internship Application
Internship Posting #
Application submitted by: Student
College/University Official
Date:
Name:
First Middle Last
Present Address:
Number and Street City State (zip code)
How long have you lived there?
Home Phone number:
Cell Phone number:
Email Address:
Emergency Contact:
Name Address Phone
College/University:
Year of Graduation:
What is your current major? Minor?
Do you speak other language(s) fluently? Yes No If yes, list:
Do you have any hobbies or talents? If so, list:
The completion of this Data Record is optional. Inclusion or exclusion
of any affirmative action data will not jeopardize or adversely affect
any internship decision.
CHECK ONE: Male Female
CHECK ANY THAT APPLY:
White Black Hispanic Asian/Pacific Islander
Native American (American Indian or Alaskan Native)
Disabled/Handicapped
Other
2
What Internship Track are you applying for?
For Semester beginning Fall 20
For Semester beginning Spring 20
For Semester beginning Summer 20
Is there a specific date you need to commence your Internship?
Are you available for a part time or full day program?
What days of the week and times are you available?
What skills do you hope to learn through this internship opportunity?
Please tell us why you are a good candidate for the Department of
Correction Internship Program?
How does your educational/academic program complement the Internship you
are seeking?
3
Have you ever applied for a position with or been employed by the
Department of Correction or any other Criminal Justice or Law
Enforcement Agency? Yes No
If yes, when?
Where? __________ Who was your Supervisor?
Have you ever been a volunteer with the Department of Correction or any
Massachusetts County Correctional Facility? Yes No
If yes, when?
Where? _____________Who was your Supervisor?
Have you ever been convicted of a felony? Yes No
If yes, provide detailed explanation:
Has any member of your immediate family or a relative (including in-laws)
ever been or is currently incarcerated in any Massachusetts State or
County Correctional Institution?
Yes No
Are you aware of any acquaintance(s) or personal friend(s) who are or
have been incarcerated?
Yes No
Please disclose the names and relevant information for all family,
friends, relatives and acquaintances incarcerated in any Massachusetts
State or County Correctional Institutions.
Name
Relation
Date
Place
Incarcerated
Charge
Please list any medication that you would need to bring with you during
Internship: ________________________________________________________
4
Please tell us about your employment history and give an example of your
most successful experience?
Have you ever been dismissed from a job/school of higher learning?
Yes No
If yes, please explain:
COMMENTS
This space is provided for your use in giving us any additional
information about yourself not already covered by this form, e.g.
interests, plans, special skills, goals or any other information that
you feel we should know in considering you for this internship.
To be completed by Intern:
Statement: I certify that the information contained in this application
is correct to the best of my knowledge and understand that falsification
of this application is grounds for removal from the Internship Program.
Date: ______________________ Signature of Intern: __
To be completed by College/University Official:
Statement: I certify that this student is in good standing at:
College/University
Date:
Signature of College/University Official: __
Title:__________________________________________________________________
**"Please bring this form to the Registrar's office for signature only".
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5
RELEASE
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF CORRECTION
I, ________________ , am approved by the Superintendent and/or
Division Head of ____________ (facility or division) to work
as an Intern.
I release and forever discharge the Commonwealth of Massachusetts
and all of its officers, agents, and employees, acting officially
or otherwise, from any and all claims, demands, action, or causes
of action on account of my death or injury to myself or damage to
my property which may occur as the result of any act by an inmate
during the performance of the above-mentioned service.
Signature:
Date:
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6
AGREEMENT TO ABIDE BY RULES
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF CORRECTION
I, _______________________________, agree to abide by all
applicable laws, rules and regulations governing persons employed
by the Massachusetts Department of Correction as well as policies
of each facility, especially those relating to confidentiality.
Signature:
Date:
Copy: Division of Human Resources/Office of Diversity
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7
Superintendent/Division Head
BACKGROUND INFORMATION REQUEST AND WAIVER
(PLEASE PRINT CLEARLY OR TYPE)
INSTITUTION/DIVISION
NEW EMPLOYEE CONTRACT EMPLOYEE
PERSONAL DATA:
NAME
LAST FIRST MIDDLE
PREVIOUS NAME AND/OR ALIAS
RESIDENTIAL ADDRESS
(Not a P.O. Box) NUMBER STREET CITY STATE ZIP
HAVE YOU EVER RESIDED IN ANOTHER STATE? IF YES, WHICH STATE (S)?
SOCIAL SECURITY NUMBER DRIVER’S LICENSE NUMBER
DATE OF BIRTH PLACE OF BIRTH SEX RACE
MOTHER’S MAIDEN NAME
FATHER’S NAME
I, , hereby release, discharge, and exonerate the Massachusetts
Department of Correction, its agents and representatives, and any person so furnishing information, for any and all
liability of every nature and kind arising out of the furnishing or inspection of such documents, records and other
information or the investigations made by or on behalf of the Massachusetts Department of Correction.
I further understand that the Massachusetts Department of Correction will conduct a background investigation which
will include a check with any past employers, a criminal records check with the local police department, the State
Police, the FBI in Washington D.C., the Massachusetts Board of Probation, Registry of Motor Vehicles and interviews
with my character references. The Department of Correction will conduct these checks as the Department deems
necessary, including but not limited to initial hire, promotion, investigations and disciplinary cases.
SIGNATURE DATE
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Commonwealth of Massachusetts Department of Correction - Student Internship Application

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Completed 18 May 2020

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