Leadership Residency / Internship
Program Application
APPLICATION COMPLETION INSTRUCTIONS AND CHECKLIST

Internship / Residency Application Completed

Resume – attached to application

Official Copy of Transcripts (as of last term completed) mailed by school to contact person below.

(Residency Only) - GMAT / GRE Results

Three (3) Completed Reference Forms – sign and give to reference with addressed stamped envelope to
be returned to contact person.
(Suggested that one reference be School / Educational related, another be Church/Volunteer related, and the third work related)

Contact Person – Application, resume, transcripts and references should be mailed to:
Robert Wells, Director of Operational Excellence
Adventist Healthcare
1801 Research Blvd
Rockville, MD 20850
Phone: (301) 315-3650, Email: rwells@ahm.com
APPLICATION QUESTIONS
Section I – This section includes your contact information, current or school address, etc. and your permanent
or home address information.
Section II – In this section, indicate which of the internships and/or residency programs that you are applying for
and what your preferred ranking is (1 = first choice, 2 = second choice and so on).
Section III – This section explores your Computer Proficiency and other skills.
a) List computer skills including word processing, spreadsheet, database and other programs.
Section IV – This section includes your most recent educational accomplishments and your current or recent
past employment. In addition to this information, you will be providing us with a current resume and official
transcripts from the school.
a) Major(s) / Minor(s)
b) GPA in Major / Overall GPA
c) Major(s) / Minor(s)
Section V – This is the Career Steps and Goals section, designed to help us get to know about you and your
career goals better.
a) Extracurricular activities in college, church or community: List leadership positions held.
b) List Honors, Awards, Scholarships.
c) Describe some of your general interests and hobbies.
d) What are your long-term career objectives? How are you preparing yourself to achieve them?
e) Why would you like to become an intern / resident or an employee of Adventist Healthcare?
Section VI – In this section we are seeking any comments you may have and your affidavit of authenticity.
Leadership Residency / Internship
Program Application
Section I: Contact & Demographic Information
First Name
Middle Initial
Last Name
Email Address
Cell Phone
Other Phone
Street Mailing Address
City
State/ Zip
Section II: Program Preferences:
Please indicate which programs interest you. Rank all that apply (1 - first choice, etc.)
*Note Internships are typically offered after completion of
Internships: 12 Week Experiences
junior year for undergrads or during a graduate program.
Accounting/ Finance Internship:
Management Internship:
Leadership Residences: Multi-Year Experiences
Accounting/ Finance Residency:
*Note Residencies are typically offered after the
completion of a graduate program.
Management Residency:
Supply Chain Residency:
Section III: Computer Proficiency
Mark Proficiency Level with a “X”
List skills or training on computers:
Novice
Intermediate
Expert
Word Processing:
Spreadsheets(s):
Databases(s):
Other:
Other:
Section IV: Most Recent Educational Endeavor and Employment History
Please attach a Resume for complete history
College
Degree
Degree Completion Year/Month
Major(s)/ Minor(s)
GPA in Major
Overall GPA
Current or Most Recent Employer
Position/ Role
Time in Position
Leadership Residency / Internship
Program Application
Section V: Career Steps and Goals
Extracurricular activities and leadership roles in College, Church or Community (List Leadership positions held)
List Honors, Awards, Scholarships
Describe some of your general interests and hobbies.
What are your long-term career objectives?
How are you preparing yourself to achieve your career objectives?
Leadership Residency / Internship
Program Application
Why would you like to become an Intern/Resident at Adventist Healthcare?
Section VI: Other – Comments, Attestation
Comments
I attest that by submitting this application, I pledge that all the information on this application and
requested materials are true, correct, and complete. I understand that in the event my application is
accepted for consideration that I, as consideration for such review and processing authorize an
investigation of all statements contained in application materials.
Signature:
Date:
Leadership Residency / Internship
Program Application
has made application with Adventist Healthcare
(First Name)
(Last Name)
Leadership Development Program for either an internship or residency program opportunity. Your confidential
evaluation of this individual in regard to the items listed will be appreciated.
RELEASE AUTHORIZATION – I authorize any and all persons, companies, educational institutions or agencies
having personal knowledge about me, to furnish requestor with any and all information in their possession
regarding me in connection with my application. I also hereby release any and all aforementioned individuals or
groups responding to such investigation for any damage due to releasing any information they may have
regarding me, whether or not it is in their records or otherwise available to them provided it relates to my
employment history or other statement made in this application, pertaining hereto. I understand this
authorization is to be part of the written employment application that I sign.
(Applicant Signature)
(Date)
Instructions: Using the following guidelines please rate the applicant in the following general areas by placing
an "X" in the appropriate box.
Rating
Performance Descriptor
Developmental Status
Excels
Performance significantly exceeds acceptable requirements
Model for Others
Good
Performance exceeds acceptable requirements
Strength
Average
Performance meets acceptable requirements
Acceptable
Fair
Performance less than acceptable requirements
Developmental Need
Poor
Performance significantly below acceptable requirements
Major Developmental Need
NA
Performance not demonstrated or observed
Unknown
Competency / Behavior
Excels
Good
Average
Fair
Poor
NA
Has applicant expressed interest in a health care career?
Yes
No
Unknown
Has applicant expressed interest in relocation for professional growth?
Yes
No
Unknown
(over)
Achievement orientation
Concern for quality and order
Initiative
Interpersonal skills
Impact and influence on others
Relationship building
Teamwork and cooperation
Analytical thinking
Conceptual thinking
Self-control, stress resistance
Self-confidence
Flexibility
Attitude towards supervision
Professional appearance
OVERALL RATING
Leadership Residency / Internship
Program Application
Additional Questions:
List applicant's areas of strength, or areas that they have been an example for others:
List applicant's developmental needs or area where growth is needed.
Additional Comments:
Reference Completed by:
(Signature)
(Print Name)
(Date)
Relationship to Applicant: (Check One):
Department / Division Chair of:
Professor of:
Employer:
Professional Associate (describe):
Church Related (Pastor or other):
Other (specify):
Please return to: Robert Wells, Director of Operational Excellence
Adventist Healthcare, 1801 Research Blvd Rockville, MD 20850
Phone: (301) 315-3650, Email: rwells@ahm.com
Thank you for taking the time to provide your assessment of this candidate. Your opinions are very valuable in
helping us to match applicants with placement openings.
Leadership Residency / Internship
Program Application
has made application with Adventist Healthcare
(First Name)
(Last Name)
Leadership Development Program for either an internship or residency program opportunity. Your confidential
evaluation of this individual in regard to the items listed will be appreciated.
RELEASE AUTHORIZATION – I authorize any and all persons, companies, educational institutions or agencies
having personal knowledge about me, to furnish requestor with any and all information in their possession
regarding me in connection with my application. I also hereby release any and all aforementioned individuals or
groups responding to such investigation for any damage due to releasing any information they may have
regarding me, whether or not it is in their records or otherwise available to them provided it relates to my
employment history or other statement made in this application, pertaining hereto. I understand this
authorization is to be part of the written employment application that I sign.
(Applicant Signature)
(Date)
Instructions: Using the following guidelines please rate the applicant in the following general areas by placing
an "X" in the appropriate box.
Rating
Performance Descriptor
Developmental Status
Excels
Performance significantly exceeds acceptable requirements
Model for Others
Good
Performance exceeds acceptable requirements
Strength
Average
Performance meets acceptable requirements
Acceptable
Fair
Performance less than acceptable requirements
Developmental Need
Poor
Performance significantly below acceptable requirements
Major Developmental Need
NA
Performance not demonstrated or observed
Unknown
Competency / Behavior
Excels
Good
Average
Fair
Poor
NA
Has applicant expressed interest in a health care career?
Yes
No
Unknown
Has applicant expressed interest in relocation for professional growth?
Yes
No
Unknown
(over)
Achievement orientation
Concern for quality and order
Initiative
Interpersonal skills
Impact and influence on others
Relationship building
Teamwork and cooperation
Analytical thinking
Conceptual thinking
Self-control, stress resistance
Self-confidence
Flexibility
Attitude towards supervision
Professional appearance
OVERALL RATING
Leadership Residency / Internship
Program Application
Additional Questions:
List applicant's areas of strength, or areas that they have been an example for others:
List applicant's developmental needs or area where growth is needed.
Additional Comments:
Reference Completed by:
(Signature)
(Print Name)
(Date)
Relationship to Applicant: (Check One):
Department / Division Chair of:
Professor of:
Employer:
Professional Associate (describe):
Church Related (Pastor or other):
Other (specify):
Please return to: Robert Wells, Director of Operational Excellence
Adventist Healthcare, 1801 Research Blvd Rockville, MD 20850
Phone: (301) 315-3650, Email: rwells@ahm.com
Thank you for taking the time to provide your assessment of this candidate. Your opinions are very valuable in
helping us to match applicants with placement openings.
Leadership Residency / Internship
Program Application
has made application with Adventist Healthcare
(First Name)
(Last Name)
Leadership Development Program for either an internship or residency program opportunity. Your confidential
evaluation of this individual in regard to the items listed will be appreciated.
RELEASE AUTHORIZATION – I authorize any and all persons, companies, educational institutions or agencies
having personal knowledge about me, to furnish requestor with any and all information in their possession
regarding me in connection with my application. I also hereby release any and all aforementioned individuals or
groups responding to such investigation for any damage due to releasing any information they may have
regarding me, whether or not it is in their records or otherwise available to them provided it relates to my
employment history or other statement made in this application, pertaining hereto. I understand this
authorization is to be part of the written employment application that I sign.
(Applicant Signature)
(Date)
Instructions: Using the following guidelines please rate the applicant in the following general areas by placing
an "X" in the appropriate box.
Rating
Performance Descriptor
Developmental Status
Excels
Performance significantly exceeds acceptable requirements
Model for Others
Good
Performance exceeds acceptable requirements
Strength
Average
Performance meets acceptable requirements
Acceptable
Fair
Performance less than acceptable requirements
Developmental Need
Poor
Performance significantly below acceptable requirements
Major Developmental Need
NA
Performance not demonstrated or observed
Unknown
Competency / Behavior
Excels
Good
Average
Fair
Poor
NA
Has applicant expressed interest in a health care career?
Yes
No
Unknown
Has applicant expressed interest in relocation for professional growth?
Yes
No
Unknown
(over)
Achievement orientation
Concern for quality and order
Initiative
Interpersonal skills
Impact and influence on others
Relationship building
Teamwork and cooperation
Analytical thinking
Conceptual thinking
Self-control, stress resistance
Self-confidence
Flexibility
Attitude towards supervision
Professional appearance
OVERALL RATING
Leadership Residency / Internship
Program Application
Additional Questions:
List applicant's areas of strength, or areas that they have been an example for others:
List applicant's developmental needs or area where growth is needed.
Additional Comments:
Reference Completed by:
(Signature)
(Print Name)
(Date)
Relationship to Applicant: (Check One):
Department / Division Chair of:
Professor of:
Employer:
Professional Associate (describe):
Church Related (Pastor or other):
Other (specify):
Please return to: Robert Wells, Director of Operational Excellence
Adventist Healthcare, 1801 Research Blvd Rockville, MD 20850
Phone: (301) 315-3650, Email: rwells@ahm.com
Thank you for taking the time to provide your assessment of this candidate. Your opinions are very valuable in
helping us to match applicants with placement openings.