| Local Coordinator Application Form |
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Name |
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SSN ( By providing your SSN, you are authorizing us to submit a CBC on your behalf. You can also submit it hereand leave this blank.) |
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Date of Birth (mm/dd/yyyy) |
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Home Address |
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City |
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State |
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ZIP |
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E-Mail |
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Years at address |
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Rent or Own |
Rent Own |
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Phone(day) |
format:xxx-xxx-xxxx |
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Phone(evening) |
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| Briefly describe why you would like to be an area representative with STS Foundation: |
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| Describe your experience with teenagers: |
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| Have you had any training and/or experience in counseling? If so please describe: |
Yes No
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| Describe any experience(s) you have had with international/intercultural exchange: |
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| Are you currently employed? |
Yes No |
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| Please name your place of employment including address: |
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| What is the name of your local High School? |
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| Please give your supervisor's name and phone number: |
Name:
Number:
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| If you have worked for your present employer for 3 years or less, please name your previous employer: |
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| Do you have a criminal record? |
Yes No |
| Has your driver's license been revoked or suspended? |
Yes No |
| Please list the name, address, and phone number of three references(non-relatives) |
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| You may click the print button now to keep a copy of the application for your records before hitting submit |
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| Department of State regulations require that all employees complete a criminal backgrpound check. Please complete the background check here. |
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