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AZCM Intern Application

Contact Information

First Name *

Last Name *

Month and Day of Birth *

Home Address *

Street, City, State and Zip Code

Home Phone Number *

Cell Phone Number

Email Address *

Occupation

Work Address

Street, City, State and Zip Code

Work Phone Number

Emergency Contact *

Name and Contact Info

Other Information

Availability *

Intern position you are interested in

Previous Experience *

Educational Background and Skills *

Foreign Languages Spoken or Read

Computer / Internet Skills *

What do you hope to gain from your intern experience? *

Have you ever been convicted and/or placed on probation for any criminal offense? *

Yes

No

A yes answer will not necessarily disqualify you.

References

Provide two non-relative references who have known you for one year of more.

Include Name, Number, and Email

Reference #1 *

Reference #2 *

Please read completely and sign below.

Interns are persons doing State of Arizona tasks/activities under the direction and control of a State authorized official and are not paid.

Media Permission *

Yes

No

I give permission for photos or video of me to be used for publicity specific to the museum’s purposes without remuneration or compensation.

Digital Signature

I, the undersigned, understand that liability coverage is extended to interns acting at the direction of a State official and within the course and scope of State authorized activities. Interns of the State are provided the same liability protection afforded employees. Thus, interns acting within the course and scope of their State authorized activities may be covered for their liability exposure as authorized interns of the State.

I also understand that as an intern with the Arizona State Library, Archives, and Public Records, I am NOT covered by the State's workers' compensation plan if injured while participating in this program.

I hereby authorize the State Library, Archives, and Public Records to perform a Motor Vehicle Records inquiry if I drive a state vehicle, or drive my own vehicle on state business. I also agree to provide information concerning vehicle insurance coverage upon request.

I understand that the State Library agency holds copyright and all other intellectual property rights to any works created as part of my position as an intern, and anything received or created while doing business for the agency may be considered a public record and belongs to the state. I have carefully read the above information and understand its contents. The above information provided by me is accurate.

Full Name (Sign Digitally) *

Date Signed *

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