+-----------------+----------------------------------------------------+
| ###             | ### Please comple                                  |
|                 | te and send application and required materials to: |
| ### ![](me      |                                                    |
| dia/image1.wmf) | INL Education Initiatives                          |
| {width="1.67361 |                                                    |
| 11111111112in"  | Attn: Una Tyng                                     |
| height="1.13819 |                                                    |
| 44444444445in"} | ### P.O. Box 1625                                  |
|                 |                                                    |
|                 | Idaho Falls, ID 83415-3810                         |
|                 |                                                    |
|                 | Questions should be directed to Una Tyng (208)     |
|                 | 526-1626 or email una@inel.gov                     |
+-----------------+----------------------------------------------------+

### 

### 

### INL DIVERSITY INTERNSHIP PROGRAM

#### **PATH and PASO Summer Internship Application**

(You may attach a resume to the application)

##### 

##### PERSONAL INFORMATION

Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Last First Middle

Home Address:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(\_\_\_\_\_\_)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Home Telephone

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

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(\_\_\_\_\_\_)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City State Zip Additional Telephone

Email Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
U.S. Citizen: YES \_\_\_\_\_ NO \_\_\_\_

**EDUCATION INFORMATION**

List in chronological order the colleges/universities attended or
currently enrolled in or attending. Please indicate your major (or
anticipated major). If you have not chosen a major, please include a
field of interest.

College/University Dates Attended Major GPA

If you will be completing high school just prior to the summer, please
complete the following information:

Name of High School
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Graduation Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ GPA
\_\_\_\_\_\_\_ ACT/SAT Score \_\_\_\_\_\_\_\_\_

Name of College/University enrolled/applied for Fall
Semester\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_

[]{.mark}

[]{.mark}

**[\*\*Applicant must send an unofficial school transcript]{.mark}\*\***

##### INL DIVERSITY INTERNSHIP PROGRAM

### PATH and PASO Summer Internship Application

##### 

##### 

##### PAST EMPLOYMENT

Employer Dates Position Reason for leaving

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

                                                    

                                                    

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

Military Service (if any)

Branch:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Dates: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\*\*Please write a brief paragraph of what area you are interested in
being placed or what you would like to accomplish during the summer
internship. List any technical skills and/or experience that relates to
your declared degree.

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

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

**INL DIVERSITY INTERNSHIP PROGRAM**

**CERTIFICATION OF GOOD STANDING**

Diversity Student Internships are awarded to enhance the educational
experience of participants by providing the opportunity to participate
in research or applied technology at a cooperating facility. The program
encourages participants to continue their education.

**UNDERGRADUATE STUDENT**

**(To be completed by College Dean or Office of the Registrar)**

  ------------ ------------------ ------------- --------------------------
  I certify                                     is a student in good
  that                                          academic standing at

               Applicant name                   

                                                

                                  majoring in        

               College or                       
               University                       

                                                

  as of                                         

               Date                             

                                                

  Dean or                         Title              
  Registrar                                     

                                                

  Phone                           Date               

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

**PLEASE E-MAIL THIS FORM TO: academic@inel.gov**

**INEEL DIVERSITY INTERNSHIP PROGRAM**

The Privacy Waiver and Release

A number of informational documents will be generated as a result of
your application. Among those documents may be application forms,
letters of recommendation, education certification, transcripts of
grades, facility endorsement, reports of graduate record examinations,
security questionnaires, etc. The Department of Energy Organization Act
(P.L. 95-91) and the Atomic Energy Act of 1954 as amended (P.L. 83-703)
authorize the information requested.

The application and related documents are reviewed by the INEEL. The
reviews are made to determine whether the applicant meets the selection
criteria established for participation in the program. Security
questionnaires and related documents are needed when security access
authorizations are required by the INEEL.

Since the informational documents are essential to ensure a fair
selection process, an applicant cannot be considered unless he or she
provides the appropriate information.

**A.** [Release of Personal Information\
]{.underline}

In accordance with the Privacy Act of 1974 (Public Law 93-579), the
Family Educational Rights and Privacy Act (Public Law 93-380), the
Energy Reorganization Act of 1974 (Public Law 93-438) and the Atomic
Energy Act of 1954 as amended, Chapter 12, Control of Information,
Section 145b, any of the following items or related attachments of
personal information which are supplied by me, may be released to the
U.S. Department of Energy (DOE), other Federal agencies, participating
Federal, industrial, and educational entities, and cognizant review
panels as needed by the INEEL Academic Center for Excellence, Inc. to
facilitate its purposes as an administrator of education programs.

a.  Application forms and related attachments

b.  Letters of recommendation

c.  Education Certifications

d.  Transcripts of grades

e.  Facility endorsements

f.  Reports of Graduate Record Examinations or other test information

g.  Personnel Security Questionnaires and attachments

h.  Summaries of research and program evaluations

  --------- ------------------------- -- ------------ -------------------------
  Print                                  Signature:   
  Name:                                               

  Date:                                               
  --------- ------------------------- -- ------------ -------------------------

\*Note: This "Release of Personal Information" must be signed and
returned with your application for consideration before an award can be
given.

**B.** [Use of other Participant Information\
]{.underline}

To promote, evaluate, or otherwise describe this award, I give
permission to the INEEL, DOE and their agents, to use any
program-related photographs in which I appear and to use and cite any
evaluative or judgmental comments, oral or written, attributable to me
which I may make about the program.

  ------------ --------------------------- -- ------- ----------------------------
  Signature:                                  Date:   

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

**\*Note: Consideration for an award is not contingent upon your consent
to this "Use of Other Participant Information"**

INEEL Education Initiatives

P.O. Box 1625, MS 3810

Idaho Falls, ID 83415-3810

Fax: (208) 526-1880

Email: <academic@inel.gov>

**INEEL DIVERSITY INTERNSHIP PROGRAM**

## 

## CONFIDENTIAL MEDICAL INFORMATION AND EMERGENCY NOTIFICATION 

Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Birth
Date\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Male Female

Street
Address\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
State\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Zip\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Home telephone \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Social Security Number\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date of last tetanus
shot\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Drug
allergies\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

Physician's
name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Physician's phone\_\_\_\_\_\_\_\_\_\_\_\_

Medical conditions or previous
surgery\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

Regular
medications\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

Special dietary requirements (include food
allergies)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

Special physical
needs\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

# EMERGENCY CONTACT INFORMATION

Emergency Contact
Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Relationship\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address of
Contact\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Work
or home phone\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[EACH PARTICIPANT IS REQUIRED TO HAVE COVERAGE UNDER A HEALTH
INSURANCE PLAN. IT IS THE RESPONSIBILITY OF THE PARTICIPANT TO HAVE
HIS/HER OWN INSURANCE COVERAGE BEFORE ARRIVING TO THE SITE.]{.mark}**

Medical/Hospital

Insurance
Carrier\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Policy #\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_