Assurity Life Insurance Internship Program
Internship: August 23, 2010 – May 20, 2011
Application Form
Due: May 21, 2010
Student Personal Information
____________________________________________________________________________
First Name
Last Name
Student ID#
High School
__________________________________________________________________________________________
Address
Zip Code
Home Telephone
Cell Phone
email
___________________________________________________________________________ I meet low income criteria
Parent(s)/Legal Guardian(s)
Address
Telephone
used by school system
_____________________________________________________________________________
Parent’s/Legal Guardian’s Occupations
Ethnic Background
(I am the first person in my
family who will attend college.)
Academic Information for Current School Year
to be completed by your School Counselor
__________________________ High School
_________ Cumulative Weighted GPA
___________ Weighted Class Rank
Total Absences This Year ________ Total Tardies This Year ________
List Courses you have taken in this area
*Related High
School Courses
Grade
Received or Anticipated
Business
Marketing
Technology
Math
* Eligibility requirements: Top 50% of class, completed Junior year, plan to attend the University of NebraskaLincoln, Union College or Nebraska Wesleyan University
I feel that the above student is a person of character. The student demonstrates the following six qualities: respect, responsibility, trustworthiness,
fairness, caring, and citizenship. The above academic information has been verified by me and I recommend this student for the Assurity Life Insurance
Internship.
Please contact me about this student. I have additional information about this student or concerns I would like to discuss with you.
__________________________________________________________________________________________
Guidance Counselor
Email
Telephone
Activities, Honors, Employment
Please list ACTIVITIES in which you have participated and HONORS which you have received during high school.
School
Community
Employment (or other time-consuming responsibilities:
Essay
Please answer the following question in the space provided.
What future educational, occupational, and personal goals do you have? What plans have you made for the
next five to ten years? Be specific. (Please attach no more than one-page response with this application form).
TWO LETTERS OF SUPPORT
Please include two letters of support from people who can speak about your activities, talents, character, and motivation. Submit
these letters with your application. Advise your references that letters may be submitted in sealed envelopes for confidentiality.
TRANSPORTATION
I have access to transportation for an internship.
I will need help with transportation if I am selected. (Transportation will be provided if you need assistance.)
The information contained herein is true and accurate to the best of my knowledge.
__________________________________________________________________________________________
Student Signature
Parent/Guardian Signature
Date
Mail by April 8 to:
Carol Andringa, CTE Curriculum
Lincoln Public Schools
5901 O Street
Lincoln, NE 68510
OR use school mail to:
Carol Andringa
Box 8
LPSDO