Internship Application Attach photo here. Personal Information

Attach photo here.
P.O. Box 40 • Hillsboro, NH • 03244
Phone: (603) 464-5555 • Fax: (603) 464-5658 • www.hismansion.com
Internship Application
Personal Information
Name _______________________________________ Age _____ Date of Birth _______________________
Current Address __________________________________________________________________________
City ______________________________________________________ State ______ Zip ________________
Primary Phone (_______) ______________________ Secondary Phone (_______) _____________________
Permanent (Mailing) Address ________________________________________________________________
City ______________________________________________________ State _______ Zip _______________
E-mail Address _______________________________________ Height _________ ft/in Weight _______ lbs
Marital Status ___ Single ___ Engaged ___ Married ___ Widowed ___ Separated ___ Divorced
Emergency Contact Information
Name ________________________________________ Relationship ________________________________
Address _________________________________________________________________________________
City ____________________________________________________ State ________ Zip ________________
Primary Phone (______) _______________________ Secondary Phone (______) ______________________
E-mail Address ___________________________________________________________________________
Education
Current School Name ______________________________________________________________________
Address _________________________________________________________________________________
City ______________________________________________________ State ________ Zip ______________
Major(s) ______________________________________ Minor(s) ___________________________________
Year in School _______________ Anticipated Graduation Date _____________________________________
List all other high schools, colleges/universities, or graduate schools you have attended.
School Name
Location
Dates Attended
Graduation Date
Degrees _________________________________________________________________________
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If you left school prematurely, please explain why.
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Employment
Are you currently employed? ___ Yes ___ No
a. Company Name ____________________________________________________________________
b. Position ________________________________________________ Full-Time _____ Part-Time _____
c. Length of Employment _______________________________________________________________
d. Supervisorʼs Name __________________________________________________________________
May we contact your employer? ___ Yes ___ No
If not, why not? _____________________________________________________________________
Approximately how many other jobs have you had? _______________________________________________
Have you served in the military? ___ Yes ___ No
If yes, how long? ____________________ What branch? ____________________________________
Please list previous employment/service experience that would be relevant to your service at His Mansion.
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If you have ever had to leave or been asked to leave an employment or service position prematurely, please
explain the occurrence in detail on a separate sheet of paper.
Church Information – Please provide information about your current church community.
Church Name ____________________________________________________________________________
Pastorʼs Name ___________________________________________________________________________
Address _______________________________________________ City ______________________________
State _____ Zip _______________ Primary Phone: (_______) ______________________________________
E-mail Address ___________________________________________________________________________
Are you a member? ___ Yes ___ No How long have you attended there? _____ Years _____ Months
Have you discussed your intent to serve at His Mansion with your pastor? ___ Yes ___ No
May we contact your pastor to discuss your candidacy? ___ Yes ___ No
If not, why not? _____________________________________________________________________
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Personal History
Please answer all of the following questions. Answering “yes” to the following questions will not necessarily
disqualify you from service. Please provide a brief explanation for any item that you have checked “yes.” Feel
free to attach a separate sheet for short explanatory answers to these questions.
Please list and explain any medical conditions or health issues.
________________________________________________________________________________________
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Have you received any diagnosis from a mental health professional? ___ Yes ___ No
If yes, what is the diagnosis? __________________________________________________________
Do you take any prescribed medications pursuant to a physician's direction? ___ Yes ___ No
If yes, please list the medication and dosage?
__________________________________________________________________________________
Is your diet restricted? ___ Yes ___ No
If yes, explain.
__________________________________________________________________________________
Do you have any allergies (e.g. drug, food, seasonal, animal, etc…)? ___ Yes ___ No
If yes, explain.
__________________________________________________________________________________
Have you ever had (or currently have) back problems? ___ Yes ___ No
If yes, explain.
__________________________________________________________________________________
Does anything hinder you from doing physical work, including heavy lifting? ___ Yes ___ No
If yes, explain.
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Have you ever had an eating disorder? (Anorexia, Bulimia, etc…) ___ Yes ___ No
If yes, explain.
__________________________________________________________________________________
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Have you ever used illegal drugs? ___ Yes ___ No
If yes, explain.
__________________________________________________________________________________
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Have you ever had a problem with substance abuse? ___ Yes ___ No
If yes, explain.
__________________________________________________________________________________
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Have you ever struggled with same-sex attraction? ___ Yes ___ No
If yes, explain.
__________________________________________________________________________________
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Have you ever been hospitalized for emotional or behavioral issues? ___ Yes ___ No
If yes, explain.
__________________________________________________________________________________
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When and where were you hospitalized?
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Have you ever been abused (mentally, emotionally, physically, or sexually)? ___ Yes ___ No
If yes, explain (use a separate sheet if necessary):
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Have you ever been an abuser (mentally, emotionally, physically, or sexually)? ___ Yes ___ No
If yes, explain (use a separate sheet if necessary):
__________________________________________________________________________________
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Describe your exposure to pornography.
________________________________________________________________________________________
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Describe your sexual history.
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Have you ever been charged with or convicted of a criminal act, regardless of whether the conviction was later
set aside or expunged? ___ Yes ___ No
If yes, please provide the details of the offenses charged and the outcome – including sentencing, if
applicable.
__________________________________________________________________________________
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Essay Questions
This application is not merely evaluative, but is also an opportunity for the internship staff to get to know you.
Your answers to the following questions will help us get to know you, while taking a reflective posture towards
yourself. Please answer the following questions thoroughly, honestly, and thoughtfully on a separate sheet of
paper in no more than two paragraphs per question.
1. Who are you?
2. Describe your past and present relationship with your mother and father (each separately).
3. Who has been the most influential person in your life? Why?
4. What is your greatest accomplishment in your life thus far?
5. What is your greatest regret in your life thus far?
6. Describe your relationship with God.
7. How did you come to know God?
8. In your understanding, what is the Gospel?
9. What do you believe about the Bible? What role does it play in your life?
10. How do you handle conflict in your relationships?
References
Please list three people we may contact for reference. Avoid using relatives or close friends. Please use other
appropriate people, such as pastors, elders, ministry leaders, mentors, etc.
1. Reference One
Name ________________________________________ Relationship ________________________________
Address _________________________________________________________________________________
City ______________________________________________________ State ________ Zip ______________
Primary Phone (______) _____________________ Secondary Phone (______) ________________________
E-mail Address ___________________________________________________________________________
2. Reference Two
Name ________________________________________ Relationship ________________________________
Address _________________________________________________________________________________
City ______________________________________________________ State ________ Zip ______________
Primary Phone (______) _____________________ Secondary Phone (______) ________________________
E-mail Address ___________________________________________________________________________
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3. Reference Three
Name ________________________________________ Relationship ________________________________
Address _________________________________________________________________________________
City ______________________________________________________ State ________ Zip ______________
Primary Phone (______) _____________________ Secondary Phone (______) ________________________
E-mail Address ___________________________________________________________________________
Please read the following statement and sign below.
I hereby certify that the answers and other information on this application are true and correct to the best of my
knowledge. I understand that any material misrepresentation or omission of facts on my part will be grounds for
dismissal from my internship at His Mansion Institute.
Signature ________________________________________________ Date ___________________________
PLEASE MAIL YOUR APPLICATION TO:
His Mansion Ministries
P. O. Box 40
Hillsborough, NH 03244-0040
Attn: Dave McHale, Internship Supervisor
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