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Personal Data
Name*
First Middle Last
Present Address*
Street Address Address Line 2 City State ZIP Code
Cellular Phone Number
E-Mail Address*
Date of Birth*
MM slash DD slash YYYY
Gender
Are you a student?
- I am a student
School Currently Attending*
Current DDS Provider
Name Type of Service

Please list name and type of service (GSE, Day, ISE, IDV etc.)
Referral Contact Information
Referral Contact Name
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Referral Contact Email
Referral Contact Address
Street Address Address Line 2 City State ZIP Code
Referral Contact Cellular Phone Number
Referral Contact Signature
Referral Contact Signed Date
MM slash DD slash YYYY
Referral Contact Name
First Middle Last
Referral Contact Email
Referral Contact Address
Street Address Address Line 2 City State ZIP Code
Referral Contact Cellular Phone Number
Referral Contact Signature
Intern Candidate Information
1. Universal Release: I authorize the release of educational and employment records concerning the intern candidate from his or her school, DDS program or Employer to UCP of Eastern CT and Project SEARCH Partners.
2. Equal Opportunity: Project SEARCH placement will be made without regard to race, color, age, sex, national origin, cultural or economic background, housing circumstances is entitled to equal opportunity for educational development.
Candidate Signature*
Signed Date*
MM slash DD slash YYYY
Future Employment Preferences and Background
What is your career of interest?*
How do you want to be employed in the community upon the completion of Project SEARCH?*
- Full-time
- Part-time
List jobs you do or have done in the school or in the community (paid or volunteer)
Employer
Contact Number
Supervisors Name/Title
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Date Started
Date Ended
Job Duties
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Contact Number
Supervisors Name/Title
- Paid
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Date Started
Date Ended
Job Duties
List other jobs you do or have done in the school or in the community (paid or volunteer)
Candidate Response Question
Why do you want to participate in Project SEARCH?*
Complete in your own words and/or person assisting will write the responses in the candidate's own words.
References:
Please provide 3 references.
Required*
Name Relationship Phone Number Email Address
Assistance
The person assisting the candidate to complete this application is:
Name*
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Title*
Organization*
Phone Nuimber*
Email*
Signature*
Date
MM slash DD slash YYYY
School Personnel Only
- Completed Application Packet (Student/Family completes and submits)
- High School Transcript (Local School/EUPISD will submit on behalf of intern)
- Attendance Record (Local School/EUPISD will submit on behalf of intern)
- Current IEP (Local School/EUPISD will submit on behalf of intern)
- Most Recent Evaluation Team Report (Local School/EUPISD will submit on behalf of intern)
Email
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Search Results for: 亚 博 是 什么-【✔️推荐AC68·CC✔️】-touch n go游戏-亚 博 是 什么rl9qm-【✔️推荐AC68·CC✔️】-touch n go游戏vwym-亚 博 是 什么8zhca-touch n go游戏u82r

Search Results for: 亚博是什么-【✔️推荐AC68·CC✔️】-touch n go游戏-亚博是什么rl9qm-【✔️推荐AC68·CC✔️】-touch n go游戏vwym-亚博是什么8zhca-touch n go游戏u82r