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
Internship Employer 1 — Employment 1 — Employer and Address	Employment Position 1 Supervisor	Employment Date 1 Dates of Work	Employment Reason For Leaving 1 Responsibilities
Internship Employer 2 — Employment 2 — Employer and Address	Employment Position 2 Supervisor	Employment Date 2 Dates of Work	Employment Reason For Leaving 2 Responsibilities
Internship Employer 3 — Employment 3 — Employer and Address	Employment Position 3 Supervisor	Employment Date 3 Dates of Work	Employment Reason For Leaving 3 Responsibilities
Internship Employer 4 — Employment 4 — Employer and Address	Employment Position 4 Supervisor	Employment Date 4 Dates of Work	Employment Reason For Leaving 4 Responsibilities

References

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

Education

Education
Type	School Name	School Address	Major Subject(s)	Graduated	Currently Enrolled
High School — High School —	School 1 School Name	Address 1 School Address	Subjects 1 Major Subject(s)	Graduated 1 Graduated	Enrolled 1 Currently Enrolled
College — College —	School 2 School Name	Address 2 School Address	Subjects 2 Major Subject(s)	Graduated 2 Graduated	Enrolled 2 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
School 1 — Extracurricular 1 — Volunteering, Clubs, Organizations, etc.	School 1 Role(s)	School 1 Responsibilities
School 2 — Extracurricular 2 — Volunteering, Clubs, Organizations, etc.	School 2 Role(s)	School 2 Responsibilities
School 3 — Extracurricular 3 — Volunteering, Clubs, Organizations, etc.	School 3 Role(s)	School 3 Responsibilities
School 4 — Extracurricular 4 — Volunteering, Clubs, Organizations, etc.	School 4 Role(s)	School 4 Responsibilities

Business Hours Available to Intern

Other
Monday	Tuesday	Wednesday	Thursday	Friday
School 1 Monday	School 1 Tuesday	School 1 Wednesday	School 1 Thursday	School 1 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

Class Schedule

Statement

Preferred Caucus

Signature

Date