Internship Application Form

Read Fully Before Continuing

This online application is used to help expidite the internship application process. You must fill in all fields as completely as possible if applicalble. Finally, you will need to type in your name and date at the bottom of the form and hit continue. A copy of the application will be electonically sent to the agency. A printable version of the application will appear that you must print, sign, and submit it to the agency for final approval. Any false statement on any part of your application may be grounds for rejection of your application, or for dismissal after you internship has begun.

Any fields left blank may delay acceptance of application. Fields marked with "*" are required.

PERSONAL INFORMATION

Name: *

SSN:

DOB:

Mailing Address:

Permanent Address:
(If different from above.)

Phone #: *

Permanent Phone # (If Different):

EMail Address: *

EDUCATION INFORMATION
Major:
Minor: (If Applicable)
Current Year : & Semester:
Graduation Year : & Semester
Overall GPA:	Criminology GPA:

INTERNSHIP INFORMATION

Internship Year : & Semester: your applying for.

Name Of Desired Internship Agency:

Agency Address:

Agency Supervisor:

Supervisor's Phone Number:

Special Interviews/Applications required by Agency:

Internship Requirements:

Requirement:	Status	Year / Semester
CCJ3011 (Criminology)
CCJ3101 (Law Enforcement)
CCJ3201 (Courts)
CCJ3301 (Corrections)
CCJ4700 (Research Methods)

CRIMINAL INFORMATION (If Applicable)

Many agencies may exclude students from placement with convictions. In order to facilitate placement, please answer the following:

Have you been convicted of a felony or a first degree misdemeanor?

*If yes, you will need to come in and speak to the Internship Director prior to placement process

List all moving violations you have received (i.e.: speeding, careless driving,etc):

Date:	Place:	Charge:	Disposition