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2. NAPA COUNTY PROBATION DEPARTMENT
   INTERN-VOLUNTEER APPLICATION
4. Name (Last, First, Middle)
5. Date
   Date
7. Address
8. Referred By
10. City
11. State
12. Zip Code
14. Home Phone
15. Mobile Phone
16. Email
18. Have you ever been convicted of any offense against the law or forfeited collateral, or are you now under charges for any offense against the law? If so, give details and present status:
20. Do you currently have any friends or family members who have been or are currently on probation or in Juvenile Hall in any County or State?

    1. No

    1. Yes
21. If yes, Please Identify the person
23. Do you have any relatives/significant other currently employed by the Napa County Probation Department?

    1. No

    1. Yes
24. If yes, Please identify the person
26. Volunteer/Internship role that you are interested in, if known?
28. What experience are you hoping to gain with us?
30. Date you can start
    Date you can start
31. How many hours are you available each day
32. Which days of the week are you available?

    Check all that apply

    1. Monday
    2. Tuesday
    3. Wednesday

    1. Thursday
    2. Friday
34. In addition to English, what other language(s) do you speak, read, write?
36. Language
37. Level

    Check all that apply

    1. Speak
    2. Read
    3. Write
38. Language
39. Level

    Check all that apply

    1. Speak
    2. Read
    3. Write
41. EDUCATION RECORD
43. High School (Name, City, State)
44. Graduation Date
    Graduation Date
48. Business or Technical School (Name, City, State)
50. Dates Attended
    Dates Attended Start Date

    —

    Dates Attended End Date
51. Degree Earned
55. College (Name, City, State)
57. Dates Attended
    Dates Attended Start Date

    —

    Dates Attended End Date
58. Degree, Major
62. College (Name, City, State)
64. Dates Attended
    Dates Attended Start Date

    —

    Dates Attended End Date
65. Degree, Subject
67. WORK HISTORY (GIVE INFORMATION ABOUT YOUR LAST 2 JOBS, STARTING WITH THE MOST RECENT)
69. 1-Employer
70. Dates Employed
    Dates Employed Start Date

    —

    Dates Employed End Date
72. Address
73. Phone
75. City
76. State
77. Zip Code
79. Your Title/Duties
81. Managers Name and Title
85. 2-Employer
86. Dates Employed
    Dates Employed Start Date

    —

    Dates Employed End Date
88. Address
89. Phone
91. City
92. State
93. Zip Code
95. In Case of Accident or Illness, please notify: (List Name, Address and Phone Number)
99. REFERENCES
101. 1-Name
102. Relationship
103. Work Phone
105. Address
106. Home Phone
108. City
109. State
110. Zip Code
114. 2-Name
115. Relationship
116. Work Phone
118. Address
119. Home Phone
121. City
122. State
123. Zip Code
127. 3-Name
128. Relationship
129. Work Phone
131. Address
132. Home Phone
134. City
135. State
136. Zip Code
140. STATEMENT AND AGREEMENT - PLEASE READ AND SIGN
142. I hereby state that all information provided on the application, and in any interview, is true, complete and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am placed as an intern or volunteer at the Probation Department or Juvenile Hall and any information provided by me is later found to be false or incomplete in any respect, the placement shall be terminated.

     I understand that Napa County may investigate my background and employment history. I further understand that Napa County may contact my previous employers and I authorize those employers to disclose to Napa County all records and information pertinent to my employment with that employer. .......................................................................................................................................................................................................................................... I hereby acknowledge that I have read the above Statement and Agreement and understand the same.

     1. I agree
144. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
146. Electronic Signature
147. Date
     Date
Leave This Blank:


151. 1. Receive an email copy of this form.
152. Email address

     This field is not part of the form submission.

153. Submit Submit and Print

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