# ![](media/image1.jpeg){width="2.625in" height="0.5083333333333333in"}Professional Internship Program

# 

# 

## General Eligibility Requirements to Apply

1.  Applicants must be students in good standing at accredited U.S.
    colleges or universities or accepted as an entering freshman or
    beginning graduate student, or received BS degree within 2 years of
    appointment dates.

2.  Overall minimum GPA requirement is 2.50 (based on A=4.0).

3.  U.S. citizen only at SRS.

## Additional Requirements for Participation

1.  Applicants must be at least 18 years of age at the time of
    appointment.

2.  Participants are required to provide proof of coverage under a
    health insurance plan **PRIOR** to beginning an appointment.

## Instructions

An application, including official transcripts and references, will be
reproduced by the Oak Ridge Institute for Science and Education and
transmitted to the facilities for review.

A complete application consists of:

Application Form: Part I -- Applicant Information Form, two pages

Part II -- Courses and Grades Pertaining to Your Major

Part III -- Description of Research Interests and Career Plans

Two References: at least one academic reference required

**Official** transcripts from **all** universities and colleges attended

1.  Complete all information requested on Parts I, II, and III.
    Incomplete applications will be delayed in processing.

2.  Sign Parts I and II. This is required; an application without
    signatures will be returned.

3.  Send Parts I, II, and III of the application to the address below.
    The applicant Data Form is optional.

4.  Request official transcripts from ALL institutions of higher
    education attended to be sent directly to the address below.

5.  Arrange for references to be sent to the address below. Two
    references are required; at least one of these must be academic. A
    letter may be sent instead of, or in addition to, the form.

> Application, official transcripts, and reference forms should be sent
> directly to the address below:
>
> Marie Woodby
>
> Professional Internship Program
>
> Oak Ridge Institute for Science and Education
>
> Science and Engineering Education, MS 36
>
> P.O. Box 117
>
> Oak Ridge, Tennessee 37831-0117
>
> Phone: (865) 576-9934 Fax: (865) 574-2845 E-mail:
> Marie.Woodby@orau.org

![](media/image1.jpeg){width="2.25in"
height="0.4361111111111111in"}Professional Internship Program

Part I, Page 1

**APPLICATION FOR:** \_\_\_\_\_\_ Savannah River Site

Scientific contact person at facility (optional)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**APPLICANT INFORMATION FORM** (Please type or print using black ink)

My application may be reviewed by other similar programs. ( ) Yes ( ) No

**Dates available for
participation**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ to
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (Month/Day/Year)

**Name**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**SSN** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

First Middle Last

**Preferred Mailing Address**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Street Name, Apartment Number, or P.O. Box

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City State Zip

**Permanent Address**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Street Name, Apartment Number, or P.O. Box

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City State Zip

**Current Phone**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Permanent
Phone** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Fax Number** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**E-mail Address**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Citizenship** U.S. Citizen ( ) Yes ( ) No If no, country
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

If no, Permanent Resident ( ) Yes ( ) No If yes, PRA Number
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Health Insurance** (required for appointment)

Company Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Effective Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_

**References** -- two persons who have been asked to transmit references
directly to ORISE

1.  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_2.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Current University**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City/State
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Graduation Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Department
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Major
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Cumulative GPA (4.0 scale) Undergraduate
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Graduate
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Degree Program** (degree working toward)

( ) Associate's ( ) Bachelor's ( ) Master's ( ) Doctoral

*At the time of appointment, I will be classified as:*

( ) Freshman ( ) Sophomore ( ) Junior ( ) Senior ( ) Post-BS ( )
Graduate Student

![](media/image1.jpeg){width="2.25in"
height="0.4361111111111111in"}Professional Internship Program

Part I, Page 2

**Computer Languages** -- list and rate your proficiency in each as
good, very good, or expert

  ---------------------- ------------- -- --------------------- -------------
  Computer Language      Proficiency      Computer Language     Proficiency

                                                                

                                                                

                                                                
  ---------------------- ------------- -- --------------------- -------------

## Academic Awards and Honors

  ----------------------------------- -----------------------------------
                                      

                                      

                                      

                                      
  ----------------------------------- -----------------------------------

**Education** -- list all previous colleges/universities attended

  -------------------- ----------------- ------------ ------------ --------
  College/University   Major             Dates        Degree       Degree
                                         Attended     Program      Date

                                                                   

                                                                   

                                                                   

                                                                   

                                                                   
  -------------------- ----------------- ------------ ------------ --------

**Employment/Experience** (paid or unpaid)

  ----------------------------- ----------------- -----------------------
  Employer                      Dates             Position/Title

                                                  

                                                  

                                                  

                                                  

                                                  
  ----------------------------- ----------------- -----------------------

## Signature\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

###  APPLICATION WILL NOT BE ACCEPTED WITHOUT SIGNATURE

![](media/image1.jpeg){width="2.25in"
height="0.4361111111111111in"}Professional Internship Program

Part II

## COURSES AND GRADES PERTAINING TO YOUR MAJOR

This form does not replace the college transcript, which is also
required.

List all courses pertaining to your major.

Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

+-----------+--------------------------------------+---------+-------+
| **Course  | **Course Name**                      | *       | **Gr  |
| Number**  |                                      | *Credit | ade** |
|           |                                      | Hours** |       |
+-----------+--------------------------------------+---------+-------+
| ###       |                                      |         |       |
|  Complete |                                      |         |       |
| d Courses |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
| #         |                                      |         |       |
| ## Curren |                                      |         |       |
| t Courses |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+
|           |                                      |         |       |
+-----------+--------------------------------------+---------+-------+

I certify that, to the best of my knowledge, the above courses and
grades are complete and correct.

**Signature**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**Date** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

### APPLICATION WILL NOT BE ACCEPTED WITHOUT SIGNATURE

![](media/image1.jpeg){width="2.25in"
height="0.4361111111111111in"}Professional Internship Program

Part III

## DESCRIPTION OF RESEARCH INTERESTS AND CAREER PLANS

#### Please print or type

Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1.  Description of Research Interests

2.  Description of Career Plans

![](media/image1.jpeg){width="2.25in"
height="0.4361111111111111in"}Professional Internship Application

Attention: Marie Woodby

##### Reference Form

Applicant Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How long and in what association have you known this applicant?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

In a group of 100 other students of comparable age and experience, how
would you rate the applicant with respect to the following:

  ------------------- ----------- ------------- ----------- ----------------- -------------- ---------------
  **Personal          **Below     **Average**   **Above     **Outstanding**   **Superior**   **Inadequate
  Characteristics**   Average**                 Average**                                    Observation**

  Motivation Toward a                                                                        
  Productive Career                                                                          

  Growth During Total                                                                        
  Period Observed                                                                            

  Imagination and                                                                            
  Originality of                                                                             
  Thought                                                                                    

  Emotional Maturity                                                                         
  and Stability                                                                              

  Ability to Work                                                                            
  with Others                                                                                

  Independence and                                                                           
  Self-Reliance                                                                              

  Leadership                                                                                 
  Potential                                                                                  
  ------------------- ----------- ------------- ----------- ----------------- -------------- ---------------

In a group of 100 other students of comparable age and experience, how
would you rate the applicant with respect to the following:

  ------------------- ----------- ------------- ----------- ----------------- -------------- ---------------
  **Capabilities**    **Below     **Average**   **Above     **Outstanding**   **Superior**   **Inadequate
                      Average**                 Average**                                    Observation**

  Mastery of                                                                                 
  Fundamentals                                                                               

  Skill/Originality                                                                          
  of Special Projects                                                                        

  Ability to                                                                                 
  Communicate                                                                                
  (Written/Oral)                                                                             
  ------------------- ----------- ------------- ----------- ----------------- -------------- ---------------

Add any descriptive comments that will assist in providing a complete
picture of the applicant's character, attitude, abilities, and
potential. Use additional sheets if necessary.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Dept.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Typed/Printed Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Return to: Marie Woodby, ORISE, MS 36, P.O. Box 117, Oak Ridge, TN
37831-0117

Phone: (865) 576-9934 Fax: (865) 574-2845

![](media/image1.jpeg){width="2.25in"
height="0.4361111111111111in"}Professional Internship Program

Attention: Marie Woodby

##### Reference Form

Applicant Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How long and in what association have you known this applicant?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

In a group of 100 other students of comparable age and experience, how
would you rate the applicant with respect to the following:

  ------------------- ----------- ------------- ----------- ----------------- -------------- ---------------
  **Personal          **Below     **Average**   **Above     **Outstanding**   **Superior**   **Inadequate
  Characteristics**   Average**                 Average**                                    Observation**

  Motivation Toward a                                                                        
  Productive Career                                                                          

  Growth During Total                                                                        
  Period Observed                                                                            

  Imagination and                                                                            
  Originality of                                                                             
  Thought                                                                                    

  Emotional Maturity                                                                         
  and Stability                                                                              

  Ability to Work                                                                            
  with Others                                                                                

  Independence and                                                                           
  Self-Reliance                                                                              

  Leadership                                                                                 
  Potential                                                                                  
  ------------------- ----------- ------------- ----------- ----------------- -------------- ---------------

In a group of 100 other students of comparable age and experience, how
would you rate the applicant with respect to the following:

  ------------------- ----------- ------------- ----------- ----------------- -------------- ---------------
  **Capabilities**    **Below     **Average**   **Above     **Outstanding**   **Superior**   **Inadequate
                      Average**                 Average**                                    Observation**

  Mastery of                                                                                 
  Fundamentals                                                                               

  Skill/Originality                                                                          
  of Special Projects                                                                        

  Ability to                                                                                 
  Communicate                                                                                
  (Written/Oral)                                                                             
  ------------------- ----------- ------------- ----------- ----------------- -------------- ---------------

Add any descriptive comments that will assist in providing a complete
picture of the applicant's character, attitude, abilities, and
potential. Use additional sheets if necessary.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Dept.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Typed/Printed Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Return to: Marie Woodby, ORISE, MS 36, P. O. Box 117, Oak Ridge, TN
37831-0117

Phone: (865) 576-9934 Fax: (865) 574-2845

![](media/image1.jpeg){width="2.25in"
height="0.4361111111111111in"}Professional Internship Program

Attention: Marie Woodby

#### Applicant Data

Applicant data is important in assessing the effectiveness of our
efforts to solicit applications from a diverse population. Your
completion and submission of this form will assist us in this regard.

Recognizing the importance of achieving a diverse group of participants
will be based on several factors. These criteria include, but are not
limited to, disciplinary field, academic records, recommendations, and
relevance to the facility's mission, ethnic background, and gender.

Providing this information is voluntary. If you decline to give this
information, it will in no way affect consideration of your application.

Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

+----+---+------------------------------------------------------------+
| #  | ( | **Caucasian** (Having origins in any one of the original   |
| #  | ) | peoples of Europe, North Africa, or the Middle East)       |
| Ra |   |                                                            |
| ce |   |                                                            |
+----+---+------------------------------------------------------------+
|    | ( | **African-American** (Having origins in any Black racial   |
|    | ) | groups of Africa)                                          |
+----+---+------------------------------------------------------------+
|    | ( | **Hispanic** (of Mexican, Puerto Rican, Cuban,             |
|    | ) | Central/South American or other Spanish culture of origin, |
|    |   | regardless of race)                                        |
+----+---+------------------------------------------------------------+
|    | ( | **American Indian** (Having origins in any of the original |
|    | ) | peoples of North America, and maintaining cultural         |
|    |   | identification through tribal affiliation or community     |
|    |   | recognition)                                               |
+----+---+------------------------------------------------------------+
|    | ( | **Asian or Pacific Islander** (Having origins in any of    |
|    | ) | the original peoples of the Far East, Southeast Asia, the  |
|    |   | Indian Subcontinent, or the Pacific Islands -- for         |
|    |   | example, India, China, Japan, Korea, Philippine Islands,   |
|    |   | and Samoa)                                                 |
+----+---+------------------------------------------------------------+
|    | ( | **Other**                                                  |
|    | ) | \_\_\_\_\_\_\_\_                                           |
|    |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|    |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+----+---+------------------------------------------------------------+

## Gender

( ) Female ( ) Male

**Birth Date**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Month Day Year

Physical/mental handicap (physical or mental impairment that
substantially limits one or more major life activities -- for example
blindness, deafness, or mobility impairment) Yes \_\_\_\_\_\_ No
\_\_\_\_\_\_