Internship Application

Fields with this color are required.

Applicant Name
 Legal First Name 
 Legal Last Name  M.I. 
 Previous Name (if applicable)  

General Information
 Last Four Digits of SSN
 Home Phone (xxx-xxxxxxx)
 Work Phone (xxx-xxxxxxx)
 Cell Phone (xxx-xxxxxxx)
 E-mail Address

Current Address
 Street  Apt.No.
 City
 State
 Zip

Emergency Contacts
 Name
 Relationship
 Home Phone (xxx-xxxxxxx)
 Work Phone (xxx-xxxxxxx)
 Same Address as Student?    Yes     No

Internship Education Requirements (check all that apply)
 1. I have above a 2.0 cumulative GPA. Yes   No
 2. I am in the last 15 hours of my A.A. degree program. Yes   No
 3. Have you scheduled a personal interview with your Program Advisor to determine eligibility and discuss internship work-site opportunities? Yes   No
 4. Have you scheduled an internship orientation meeting with the Internship coordinator? Yes   No
 5. Have you arranged an internship placement with a company? Yes   No