Internship Application

Please note : you have 30 minutes to complete this form.

General Information

First Name

Last Name

Middle Initial

Phone

Present Address

Address Line 1

Address Line 2

City

State

Zip

County

Permanent Address

Address Line 1

Address Line 2

City

State

Zip

County

Employment / Internship History (Please list your most recent employment first)

Employment History
Employer/Internship and Address	Supervisor	Dates of Work	Responsibilities
Employment/Internship 1 Employer and Address — Employment/Internship 1 — Employer and Address	Employment/Internship 1 Supervisor Supervisor	Employment/Internship 1 Dates Dates of Work	Employment/Internship 1 Responsibilities Responsibilities
Employment/Internship 2 Employer and Address — Employment/Internship 2 — Employer and Address	Employment/Internship 2 Supervisor Supervisor	Employment/Internship 2 Dates Dates of Work	Employment/Internship 2 Responsibilities Responsibilities
Employment/Internship 3 Employer and Address — Employment/Internship 3 — Employer and Address	Employment/Internship 3 Supervisor Supervisor	Employment/Internship 3 Dates Dates of Work	Employment/Internship 3 Responsibilities Responsibilities
Employment/Internship 4 Employer and Address — Employment/Internship 4 — Employer and Address	Employment/Internship 4 Supervisor Supervisor	Employment/Internship 4 Dates Dates of Work	Employment/Intership 4 Responsibilities Responsibilities

References (Please provide at least one reference)

References
Name	Relationship	Phone
Reference 1 Name — Reference 1 — Name	Reference 1 Relationship Relationship	Reference 1 Phone Phone
Reference 2 Name — Reference 2 — Name	Reference 2 Relationship Relationship	Reference 2 Phone Phone
Reference 3 Name Name — Reference 3 —	Reference 3 Relationship Relationship	Reference 3 Phone Phone

Education

Education
Type	School Name	School Address	Major Subject(s)	Graduated	Currently Enrolled
High School — High School —	High School School Name	High School Address School Address	High School Major Subject(s) Major Subject(s)	High School Graduated Graduated	High School Enrolled Currently Enrolled
College — College —	College School Name	College Address School Address	College Major Subject(s) Major Subject(s)	College Graduated Graduated	College Enrolled Currently Enrolled

Current GPA

Anticipated date of graduation

Please list the date you are able to start interning:

Would this internship be part of an academic/internship program: Yes or No

If yes, which academic program?

Extracurriculars
Volunteering, Clubs, Organizations, etc.	Role(s)	Responsibilities
Volunteering, Clubs, Organizations 1 — Extracurricular 1 — Volunteering, Clubs, Organizations, etc.	Volunteering Roles 1 Role(s)	Volunteering Responsibilities 1 Responsibilities
Volunteering, Clubs, Organizations 2 — Extracurricular 2 — Volunteering, Clubs, Organizations, etc.	Volunteering Roles 2 Role(s)	Volunteering Responsibilities 2 Responsibilities
Volunteering, Clubs, Organizations 3 — Extracurricular 3 — Volunteering, Clubs, Organizations, etc.	Volunteering Roles 3 Role(s)	Volunteering Responsibilities 3 Responsibilities
Volunteering, Clubs, Organizations 4 — Extracurricular 4 — Volunteering, Clubs, Organizations, etc.	Volunteering Roles 4 Role(s)	Volunteering Responsibilities 4 Responsibilities

Business Hours Available to Intern

Weekly Schedule
Monday	Tuesday	Wednesday	Thursday	Friday
Monday Availability Monday	Tuesday Availability Tuesday	Wednesday Availability Wednesday	Thursday Availability Thursday	Friday Availability Friday

Your State Representative

PLEASE ATTACH A COPY OF YOUR RESUME, CURRENT CLASS SCHEDULE AND A ONE-PAGE (200 WORD) STATEMENT WHICH OUTLINES YOUR INTEREST IN BECOMING AN INTERN.

Upload Resume (PDF, DOC, DOCX)

Class Schedule (PDF, DOC, DOCX)

Statement of Interest (PDF, DOC, DOCX)

Preferred Caucus

Signature

Date