Interactive Intern Application

AMERICAN SAMOA GOVERNMENT
SENATOR INOUYE INTERNSHIP PROGRAM
APPLICATION FOR INTERNSHIP

Office of the Governor
Executive Office Building - Third Floor
P.O BOX 485
Pago Pago, American Samoa, 96799
Phone: (684) 633-4116
Facsimile: (684) 633-2269

Personal Information

Name

Date of Birth

Social Security Number

Citizenship	U. S. Citizen
	U. S. National
	Other

Mailing Address
Street / PO Box
City .................	State	Zip

Home Phone Facsimile Mobile Please include Area and Country Codes

email validate email

Place of Birth
Country
City	State
Village

Type of Identification and Number
(i.e. Passport, Driver's License, Voter Registration, Etc.)
Type
Number

Education

LIST ANY SPECIALIZED SCHOOLS, TRAINING, CERTIFICATION, AND/OR LICENSES. If space provided is not sufficient list the most recent information.

Education Completed: High School Junior College University

School Dates Total Years Major/Minor
School Dates Total Years Major/Minor
School Dates Total Years Major/Minor
School Dates Total Years Major/Minor
School Dates Total Years Major/Minor
School Dates Total Years Major/Minor
School Dates Total Years Major/Minor

Residence History

In this section you are required to complete the following chart with information on your current and past residencies. Begin listing the address of every residence in which you have resided in within the past (5) five years. Include in this list, the addresses of your college residences (dormatories & apartments). To ensure that the information is logged into our databases correctly, we ask that you review your information thoroughly. Make sure there are no gaps in the timeline of dates. Begin with the earliest address, end with the most recent. In the last column labeled " years", please list the number of years that you lived at that residence.

Street PO Box City State Zip Years
Street PO Box City State Zip Years
Street PO Box City State Zip Years
Street PO Box City State Zip Years
Street PO Box City State Zip Years

Employment History

Fill in the following fields with the correct information. List below your current employer, regardless of the type of business, occupation, profession or length of time employed. If you have never been employed, please select here and continue on to Section #5 leaving the chart blank.

Employer

Supervisor

Address

Street

City State Zip

Position

From

Employer

Supervisor

Address

Street

City State Zip

Position

From

Employer

Supervisor

Address

Street

City State Zip

Position

From

References

List at least three personal references. Please make sure that the reference contact information is current and complete. References will be contacted at random during the screening process.

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

You may send an email with this form to include any additional information.

NOTE: Please print the completed application before submitting. Bring the printed copy to the interview. Use the print features in your browser and set the page orientation to landscape for best results. The data captured in this online form will be sent to a reviewer.