United Studies, Inc. Local Coordinator Application

PLEASE NOTE: 1. Local Coordinators are compensated as an independent contractor, according to the number of students supported per year. 2. United Studies Local Coordinators mentor international youth for either an academic semester or academic year program.

3. United Studies Local Coordinators should demonstrate strong ties to their communities.

4. United Studies is hiring Local Coordinators across the United States.

Personal Information

First Name:*

Middle Name:

Last Name:*

Name you'd like to be called when working for United Studies:

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Daytime Phone Number*

Daytime Phone Number:*

Evening Phone Number (if different from daytime):

Gender*

MaleFemale

Are you 21 years or older?*

YesNo

Date of Birth*

Date

Preferred T-Shirt Size (unisex sizing):*

Have you had any contact with any child protective services agency in the past?*

YesNo

If yes, please indicate when and for what reason(s).

Have you ever been convicted of a crime?*

YesNo

If yes, please indicate when and for what reason(s).

Have you ever applied to this company before?*

YesNo

If yes, was your application rejected? Please explain:

Are you legally authorized to work in the US?*

YesNo

Education

Last Year of School Completed:*

High School Name, City, and State*

Years Attended*

Did You Graduate?*

YesNo

College

Years Attended

Did You Graduate?

YesNo

Degree

College

Years Attended

Did You Graduate?

YesNo

Degree

Trade or Business School

Years Attended

Did You Graduate?

YesNo

Degree

Employment

Please list all employment that will fit here, beginning with most recent.

Name/Location of Employer:*

From - To: (MM/YY - MM/YY)*

Position:*

Reason for Leaving:*

Name/Location of Employer:

From - To: (MM/YY - MM/YY)

Position:

Reason for Leaving:

Name/Location of Employer:

From - To: (MM/YY - MM/YY)

Position:

Reason for Leaving:

Name/Location of Employer:

From - To: (MM/YY - MM/YY)

Position:

Reason for Leaving:

U.S. Military Service:

Rank:

Additional Information

How did you learn about this position? If referred by someone, list their name.*

What attracts you to this role?*

Please describe your involvement in your community - for example, activities through volunteer, athletic, religious, or other community organizations in which you have participated - and, if applicable, how you believe it has prepared you for the role of Local Coordinator.*

Please describe any experience you have had working with youth and, if applicable, how you believe it has prepared you for the role of Local Coordinator.*

Have you had a previous affiliation in any way with the Secondary School Student program and/or international exchange students (i.e. hosting, placing, or monitoring exchange students)?*

YesNo

If yes, please indicate the name of the sponsor organization, describe the nature of your affiliation with the organization (i.e. hosting, placing, or monitoring one or more exchange students), and list the dates of your affiliation with that organization.

Do you have any other exchange program experience?*

YesNo

If yes, please indicate the name of the organization, the nature of your affiliation with the organization, and the dates of your affiliation with the organization.

Please describe any other special experiences or credentials that you believe will better prepare you for this position, including but not limited to experience participating in a cultural exchange, studying a language, traveling to other countries, or communicating with people of other cultures.*

If you have any special skills that you believe will better prepare you for this position, please write about them here.

References

Please provide the names of three persons, not related to you, whom you have known at least one year.

Name*

Years known*

How you know the person*

E-mail*

Mailing Address*

Daytime Phone Number:*

Evening Phone Number (if different from daytime)

Email:

Name*

Years Known*

How you know the person*

E-mail*

Mailing Address*

Daytime Phone Number*

Evening Phone Number (if different from daytime)

Email:

Name*

Years Known*

How you know the person*

E-mail*

Mailing Address*

Daytime Phone Number*

Evening Phone Number (if different from daytime)

Email:

Background Check

A Criminal Background check is required to serve as a Local Coordinator. Submit yours online at ClearStar Background Check.

Signature

Your signature below will certify that you agree to the following:

"I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am under contract, my contract may be terminated at any time.

In consideration of my contract, I agree to conform to the company's rules and regulations, and I agree that my contract and compensation can be terminated, with or without cause and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my contract may be changed, with or without cause, and without notice, at any time by the company. I understand that no company representative, other than president or executive director, and then only in writing and signed by the president or executive director, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing."

Signature:*

Today's Date:

Date