WD&E Administrative Information Form

First Name

Middle Name

Last Name

Preferred First Name

Permanent Phone

Cell Phone

LBNL Internship Appointment

Congratulations! You have been approved for an LBNL internship.

Program

Term

Academic Year

Please indicate your decision:

I ACCEPT this appointmentI DECLINE this appointment

Permanent Address

Street Address

City

State/Province

Postal Code

Country

Emergency Contact

Emer. Contact Full Name

Emer. Contact Relationship

Emer. Contact Street Address

Emer. Contact City

Emer. Contact State

Emer. Contact Zip Code

Emer. Contact Primary Phone

Emer. Contact Alt. Phone

Citizenship Information

Are you a U.S. Citizen?

U.S. CitizenPermanent ResidentForeign Resident

Permanent Residence Information

Country of Citizenship

PRA No.

PRA Expiration Date

Administrative Information

In order to analyze, benchmark and improve on our commitment to diversity and inclusion at Workforce Development & Education (WD&E) at Berkeley Lab, we ask that you respond to the several demographic questions on this form. These questions are important to the integrity of our programs. Your responses will only be used for internal institutional purposes as well as external reporting. As with all demographic data on this form, your responses will only be shared in aggregate. By responding to the following questions, you consent to allow WD&E at Berkeley Lab to use the information collected for internal research and diversity, inclusion, and belonging efforts.

Gender

Ethnicity

Date of Birth

Place of Birth

Date of Last Final Exam

Date of Last Day of School

Are you a returning affiliate or former employee?

Returning AffiliateFormer EmployeeNot Applicable

Mickey Leland Energy Fellowship?

YesNo

Do you have an active medical insurance policy?

YesNo

Travel Plans

Travel TO LBNL

Travel Date

LBNL Arrival Date

Travel Method

CarAirBusTrain

Travel Route

From City

To City

Flight Preferences

Airline

Flight No.

Flight Time

From Airport

To Airport

Travel FROM LBNL

LBNL Departure Date