United Studies, Inc. Area Representative Application

PLEASE NOTE: 1. Local Coordinators are compensated on a contract-basis, according to the number of students supported per year. Most choose to work with just one or a few students, though some choose to take on many. 2. 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

City State / Province

Postal / Zip Code Country

E-mail *

Daytime Phone Number: *

Evening Phone Number (if different from daytime):

Gender *

Male Female

Are you 21 years or older? *

Yes No

Date of Birth *

Date

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

Yes No

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

Have you ever been convicted of a crime? *

Yes No

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

Have you ever applied to this company before? *

Yes No

If yes, was your application rejected? Please explain:

Education

Last Year of School Completed: *

11 12 Vocational Associate Bachelor Graduate Doctorate

High School Name, City, and State *

Years Attended *

Did You Graduate? *

Yes No

College

Years Attended

Did You Graduate?

Yes No

Degree

College

Years Attended

Did You Graduate?

Yes No

Degree

Trade or Business School

Years Attended

Did You Graduate?

Yes No

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? *

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)? *

Yes No

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? *

Yes No

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

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."

Please use your initials and month and day of your birth as your signature (for example, Mary Elizabeth Smith with a birthday of January 8 would sign "MES0108").

Signature: *

Clear

Today's Date:

Date