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Internship Application

Personal

To Applicant: We appreciate your interest in our organization and assure you that we are interested in your qualifications. A clear understanding of your background and work history will aid us in placing you in the internship that best meets your qualifications.

First Name:
Middle Initial:
Last Name:
Present Address:
City:
State:
Zip:
Telephone:
Email:

Sex :

Age (if under 18):

Have you been convicted of a crime in the past ten years which has not been annulled or expunged or sealed by a court:

If yes, describe in full:

NOTE: Police record check is a condition of internship.

 

Dates/Semester you wish to intern.

Type of internship desired.

Number of hours required.

What are your goals for this internship?

Level of Education required for your direct supervisor.

Please provide a copy of syllabus and information about insurance coverage for internship.

Record of Education

High School


City, State


Course of Study

Years Completed

Did you Graduate?

List diploma or degree:


Undergraduate College or University


City, State


Course of Study

Years Completed

Did you Graduate?

List diploma or degree:


Graduate College or University


City, State


Course of Study

Years Completed

Did you Graduate?

List diploma or degree:

Employment History (past employment, internships and/or volunteer experience)
Company
Address:
City:
State:
Zip:
Telephone:

Dates employed:

Describe the work you did:

Type (Employment, Internship or Volunteering):



Company
Address:
City:
State:
Zip:
Telephone:

Dates employed:

Describe the work you did:

Type (Employment, Internship or Volunteering):

 


Company
Address:
City:
State:
Zip:
Telephone:

Dates employed:

Describe the work you did:

Type (Employment, Internship or Volunteering):

 


May we contact the employers above?

If not, indicate which one(s) you do not wish us to contact?

 


 

Personal References (not relatives)


Name:
Address:
City:
State:
Zip:
Telephone:
Email:

 

Name:
Address:
City:
State:
Zip:
Telephone:
Email:

 

Name:
Address:
City:
State:
Zip:
Telephone:
Email:


Please read below:

We appreciate your interest in interning with Brook Lane.

  1. I give permission to Brook Lane to investigate any and all information concerning my application in order to determine my qualifications. This includes, but is not limited to TB testing, criminal background, employment, and personal reference checks. Some placements may require a drug test. I understand any misrepresentation of facts contained in this application may be cause for my rejection or dismissal.
  2. I agree to be photographed by Brook Lane.
  3. I agree to abide by all Brook Lane policies and regulations. I understand that this application and any other such documents are not contracts of employment, and that any intern who is placed may voluntarily leave, and/or may be dismissed by Brook Lane at any time for any reason.
  4. In the event of resignation or dismissal, I agree to return all Brook Lane property loaned to me.

My signature or typing of my name on electronic application indicates that I have read, understood, and consented to the above statements. This authorization or photocopy shall serve as consent for Brook Lane to request any information concerning my application.

I have read and agree to the terms above

Name:     Date:  


 

1-800-342-2992
(301) 733-0330
FAX (301) 733-4038

13121 Brook Lane
P.O. Box 1945, Hagerstown, MD 21742

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