EOEEA Exec Office of Energy and Environmental Affairs

A. Applicant Information

Date of Application(Required)

Email Address(Required)

Name(Required)

First Last

Present Address(Required)

Street Address Address Line 2 City State ZIP Code

Permanent Address(Required)

Street Address Address Line 2 City State ZIP Code

Present Phone #

Permanent Phone #

Cell Phone(Required)

School Currently Attending(Required)

Major Area of Study(Required)

Years or Semesters Attended(Required)

Current Level

Date Available to Start

Gender Identification:

Male

Female

Other

Race Identification

White

Black

Hispanic

Asian/Pacific Islander

Native American

Please check one box. 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.

Please indicate the top two internships in which you are interested from the list above.

1st Choice(Required)

2nd Choice(Required)

Cover Letter(Required)

Drop files here or

Max. file size: 50 MB.

Resume(Required)

Drop files here or

Max. file size: 50 MB.

This is a Confidential Insert Applicants are Encouraged but are Not Required to Complete

The Commonwealth of Massachusetts is committed in spirit, as well as in action, to abide by all laws dealing with equal employment opportunity. It is our policy to guarantee equal employment opportunities for all qualified persons without regard to their disability which can be reasonably accommodated.

Further, the Commonwealth will act in good faith, to affirmatively recruit and consider for promotion individuals in protected categories. Disability is not a factor in employment, promotion, transfer, compensation, lay-off, disciplining and termination, unless there is a bona fide occupational qualification.

In order to effectively monitor the success of our recruitment and employment efforts, it is requested that you provide the following information.

The completion of this Data Record is optional. If you choose to volunteer the requested information please note that all Affirmative Action Data Records are kept in a confidential file and are not a part of your application for employment or your personnel file. Your cooperation is voluntary. Inclusion or exclusion of any affirmative action data will not affect any employment decision.

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Check if the following is applicable

I am a person with a disability

A disability means a physical or mental impairment that substantially limits one or more major life activities; a record of such impairment; or being regarded as having such an impairment. (“Major Life Activities” includes but is not limited to functions such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working). Information on disability is maintained by the ADA Coordinator.