INTERNSHIP APPLICATION

Department of Criminology

Indiana University of Pennsylvania

Semester of Internship Desired: ___________________ Application Date: ____________________

Name: ____________________________ Banner #ID: ______________ DOB: ____________

Campus/Local Address: Permanent Address:

___________________________________ ___________________________________

___________________________________ ___________________________________

___________________________________ ___________________________________

Phone: _______________________________ Phone: __________________________________

E-mail: _______________________________ E-mail: __________________________________

Can you relocate? _______Car available? _______ Projected Graduation Date: ____________

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What are your interests for this internships and the future?

Have you made any contacts? ________ If Yes, Date of Contact: ___________________________

Agency Name: ________________________________________________________________

Agency Address: __________________________________________________________

__________________________________________________________

__________________________________________________________

Contact Person: ___________________________________ Phone Number: _______________

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At the time of the expected internship:

Total Semester hours completed: _______ Total Criminology hours completed: _______

Overall GPA: ___________

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Final Placement

Agency Name: ___________________________________________________________

Agency Address: _________________________________________________________

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Contact Person: ____________________________ Phone Number: ______________________

Letter sent to confirm/initiate (y or n) include date: __________________________________________