Please Print Out, Complete and Mail This Form To:
St Joseph’s House of Hospitality Contact: Tim Sigrist 585-235-6162
PO Box 31049
Rochester, NY 14603 Today's Date ___________
Name:_______________________ SS Number ________________ Birth Date ____________
Address: ________________________________ City _____________ State ___ Zip _______
How long at this address? _________ Phone: Day ________________ Night ___________________
Married? ________ Dependents?______ Any child support obligations? __ Yes __ No
E-mail address? _______________________ Emergency contact __________________________
Relationship ______________ Location ________________ Phone ________________________
How did you hear of us? _________________________________________________
EDUCATION
High School _____________________ Date graduated _________ Location________________
College ___________________ Graduated? _____ Date _________ Majors ________________
(Page 1 of 3)
_____________________________________________________________________________________
EMPLOYMENT HISTORY (starting with most recent)
1. Employer _____________________ Address________________________________________
Dates__________ Responsibility_________________________________________________
2. Employer ______________________ Address ______________________________________
Dates ____________ Responsibility _______________________________________________
3. Employer ______________________ Address_______________________________________
Dates _____________ Responsibility _______________________________________________
4. Employer _____________________ Address_______________________________________
Dates _____________ Responsibility ________________________________________________
_____________________________________________________________________________________
SKILLS and INTERESTS
What special talents do you have? _______________________________________________________________
Have you ever participated in acts of civil disobedience? _______________________________________________________________
What are your special interests? _________________________________________________________________
Do you have a current valid drivers license _______ State _______ ID # ___________________
Page 2 of 3
_____________________________________________________________________________________
REFERENCES (persons who have known you at least a year – but not relatives)
1.) Name ________________________
Address ________________________________________________________
Phone _______________________ How long have they known you? _____________
2.) Name __________________________
Address _______________________________________________________
Phone ________________________ How long have they known you? _____________
3.) Name ___________________________
Address ______________________________________________________
Phone __________________________ How long have they known you? _______________
_____________________________________________________________________________________
PERSONAL STATEMENTS
1.
Why do you want to live in a Catholic Worker Community?
(Respond on a separate sheet of paper; approx. 250 words)
2. What are your short and long-term goals?
(Respond on a separate sheet of paper; approx. 250 words)
_____________________________________________________________________________________
Please Enter Your Program Choices and Dates Below:
For Alternative Winter Break- Select One Weekly Session: ________TBA ______ TBA
For Alternative Spring Break- Select One Weekly Session: ________TBA ______ TBA
_____________________________________________________________________________________
For Summer Transformative Internship- June 1- Aug. 15 _____ Full ____ Partial (specify dates) _____________________________________________________________________________________
For Live-in Staff Positions:
Date you will be available ___________ Length of service: ________ 1 year ______other _____
_____________________________________________________________________________________
Signature _________________________________ Date____________
App. Form Revised 6/11/10 |
