Name *

First Name

Last Name

Address *

Permanent Residence

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Supervisor *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Supervisor

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Pastor, Minister or Youth Worker

First Name

Last Name

Phone

(###)

###

####

Employer, Volunteer Supervisor, or Teacher

First Name

Last Name

Phone

(###)

###

####

Personal Acquaintance

First Name

Last Name

Phone

(###)

###

####

I am legally eligible to work in Canada *

Yes

No

Are you a VISA student? *

Yes

No

I have a current vulnerable sector police check done *

Check was completed in the past 12 months

Yes

No

Have you ever been convicted of a criminal offence for which a pardon has not been granted? *

No

Yes

*

I hereby certify that the facts given on this application are true and complete to the best of my knowledge. I understand that if I am accepted for an internship position and portions of this application are found to be false, this is sufficient cause for my dismissal. I understand that if I am considered for the Summer Internship Program I will be required to submit a police reference check.

Today's Date *

MM

DD

YYYY