Space Science and Engineering Internship for summer 2014
Application Instructions
Complete all areas of the following pages. Enclose a copy of your transcript, a resume, this completed application
form, and any other relevant supporting material (list of publications, etc.). E-mail the packet to
employment@usurf.usu.edu or send the entire packet to:
The Space Science and Engineering Internship Program
C/O Kory Jenkins
The Space Dynamics Laboratory
1695 North Research Park Way
North Logan, UT 84341-1947
Questions will be answered by Kory Jenkins via email at employment.usurf.usu.edu Equal access to programs,
services, and employment is available to all persons. Those applicants requiring accommodation to the
application and/or interview process should contact Kory Jenkins in Human Resources.
APPLICATION
Name ___________________________________________
Last
First
E-mail:
Middle
Address _________________________________________________________________________________
Street
City
State
Zip
Home phone: _______________ Work/school phone:_______________ Cell phone:_______________
Are you 18 years or older? __ Yes
US Citizenship?
Yes (required)
__ No
No
Because of security clearance restrictions, US
citizenship is required to be eligible for the internship
program
Have you been convicted of a felony in the last seven (7) years? ___ Yes ___ No
May we forward your resume to other organizations who offer similar internship opportunities? __ Yes __ No
Date you can start internship _________
Date you must leave internship
_________
Can you perform the essential functions of the job applied for with or without accommodation? ___ Yes ___ No
Are you employed now?
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Yes
No
If so, may we inquire of your present employer? ___ Yes ___ No
EDUCATION
Name and location of school
Number of years attended
Major
GPA
High School
College Or University
College or University
List Awards, scholarships, etc ____________________________________________________________
_________________________________________________________________________________________
Summarize any job-related training, skills, licenses, certificates and/or special characteristics you possess
__________________________________________________________________________________________
__________________________________________________________________________________________
U. S. Military Service ___ Yes ___ No
Branch of Service _______________________________________
Brief description of duties
EMPLOYMENT HISTORY
Employer
Start Salary
End Salary
Summarize nature of work
Telephone No.
Supervisor
Date from:
Job Title
Reason for leaving
Date to:
Employer
Start Salary
End Salary
Summarize nature of work
Telephone No.
Supervisor
Date from:
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Job Title
Reason for leaving
Date to:
__________________________________________________________________________________________
Employer
Start Salary
End Salary
Summarize nature of work
Telephone No.
Supervisor
Job Title
Reason for leaving
Date from:
Date to:
__________________________________________________________________________________________
REFERENCES
List name and telephone number of three school/work references who are not related to you.
Name
Business
Telephone
Years known
APPLICANT CERTIFICATION
By submitting this application, it is understood and agreed upon that any misrepresentation by me on this application will be sufficient
cause for cancellation of this application and/or separation from the employer’s service if I have been employed. I give the employer
the right to investigate all references and to secure additional information about me, if job-related. I hereby release from liability the
employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such
information. The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question
on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited
by local, state, or federal law. I understand that just as I am free to resign at any time, the employer reserves the right to terminate my
employment at any time, with or without cause and without prior notice. I understand that no representative of the employer has the
authority to make any assurances to the contrary. I understand that it is this company’s policy not to refuse to hire a qualified
individual with a disability because of this person’s need for an accommodation that would be required by the ADA.
Dear Applicant:
The Space Dynamics Laboratory is a federal government contractor. As a matter of company policy as well as
applicable law, we are required to keep records and perform certain analyses of our applicant pool by race,
ethnicity, and gender. Since such analyses are only possible if we know the EEO profile of our applicants, we
are using this means to ask you to complete this survey and return it to us promptly.
Although the information which applicants provide does not at all affect their prospects for employment and is,
in fact, treated very confidentially, it is nevertheless very important to us. For any statistical analysis to be
meaningful we must have information on as many applicants as possible and it is just as important to collect this
information from men and non-minorities as it is to obtain it from women and minority group members.
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We appreciate that some applicants will find this request intrusive and we regret this. However, please be
advised that we are required by the government to keep such records and perform such analyses; your
cooperation will allow us to be accurate.
The Space Dynamics Laboratory is an Affirmative Action/Equal Opportunity Employer committed to providing
equal employment opportunity without regard to an individual’s race, color, religion, age, gender, sexual
orientation, veteran status, national origin or disability.
The categories listed below are those used by the U.S. Bureau of Census and Department of Labor and are the
only options available for Federal reporting purposes.
Select One
Select One
Name___________________________________
Sex
 Male
Race
 White
 Female
 Black or African American
 Hispanic or Latino
 Asian or Pacific Islander
 Native Hawaiian or other Pacific Islander
 American Indian, Eskimo or Aleut
 Two or More Races
Select One
Ethnicity (Are you Hispanic or Latino?)
 No, not Hispanic or Latino
 Yes, Hispanic or Latino- A person of Cuban, Mexican, Puerto Rican, South or Central America or other
Spanish culture or origin regardless of race.
What is your disability status? For a full overview of what entails disability status please review this document
YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON’T HAVE A DISABILITY
I DON’T WISH TO ANSWER
This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of
1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires
Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans;
(2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces
service medal veterans. These classifications are defined as follows:
A "disabled veteran" is one of the following:
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a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the
receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of
Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected
disability.
A "recently separated veteran" means any veteran during the three-year period beginning on the date of such
veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S.
military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge
has been authorized under the laws administered by the Department of Defense.
An Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S.
military, ground, naval or air service, participated in a United States military operation for which an Armed
Forces service medal was awarded pursuant to Executive Order 12985.
Protected veterans may have additional rights under USERRA--the Uniformed Services Employment and
Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the
uniformed service, you may be entitled to be reemployed by your employer in the position you would have
obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S.
Department of Labor's Veterans
Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.
If you believe you belong to any of the categories of protected veterans listed above, please indicate by
checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this
information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake
pursuant to VEVRAA.
I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED
ABOVE
I AM NOT A PROTECTED VETERAN
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