Internship Application You must have JavaScript enabled to use this form. We appreciate your interest in an internship at Brook Lane. Please complete the following information regarding your background and work history to help us place you in the internship that best meets your qualifications. Personal First Name: Middle Initial: Last Name: Present Address: City: State: Zip: Telephone: Email: Sex: Male Female 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? Yes No If yes, describe in full: NOTE: Police record check is a condition of an internship at Brook Lane. 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: If selected, you will need to provide a copy of syllabus and information about insurance coverage for internship. Record of EducationHigh School (Click here to expand) School Name City, State Course of Study Years Completed 1 2 3 4 Did you Graduate? Yes No List diploma or degree: Undergraduate College or University (Click here to expand) School Name City, State Course of Study Years Completed 1 2 3 4 Did you Graduate? Yes No List diploma or degree: Graduate College or University (Click here to expand) School Name City, State Course of Study Years Completed 1 2 3 4 Did you Graduate? Yes No List diploma or degree: Employment History(past employment, internships and/or volunteer experience)Company 1 (Click here to expand) Company Name: Address: City: State: Zip: Telephone: Dates employed: Describe the work you did: Type (Employment, Internship or Volunteering): Company 2 (Click here to expand) Company Name: Address: City: State: Zip: Telephone: Dates employed: Describe the work you did: Type (Employment, Internship or Volunteering): Company 3 (Click here to expand) Company Name: Address: City: State: Zip: Telephone: Dates employed: Describe the work you did: Type (Employment, Internship or Volunteering): May we contact the employers above? Yes No If not, indicate which one(s) you do not wish us to contact? Personal References(Please do not use relatives)Reference 1 (Click here to expand) Name: Address: City: State: Zip: Telephone: Email: Reference 2 (Click here to expand) Name: Address: City: State: Zip: Telephone: Email: Reference 3 (Click here to expand) Name: Address: City: State: Zip: Telephone: Email: Applicant's Statement & Signature: I give Brook Lane permission 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. I agree to be photographed by Brook Lane. 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. In the event of resignation or dismissal, I agree to return all Brook Lane property loaned to me. Entering my name in the field below 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. Agree I have read and agree to the terms above (required for submission) Name:
You must have JavaScript enabled to use this form. We appreciate your interest in an internship at Brook Lane. Please complete the following information regarding your background and work history to help us place you in the internship that best meets your qualifications. Personal First Name: Middle Initial: Last Name: Present Address: City: State: Zip: Telephone: Email: Sex: Male Female 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? Yes No If yes, describe in full: NOTE: Police record check is a condition of an internship at Brook Lane. 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: If selected, you will need to provide a copy of syllabus and information about insurance coverage for internship. Record of EducationHigh School (Click here to expand) School Name City, State Course of Study Years Completed 1 2 3 4 Did you Graduate? Yes No List diploma or degree: Undergraduate College or University (Click here to expand) School Name City, State Course of Study Years Completed 1 2 3 4 Did you Graduate? Yes No List diploma or degree: Graduate College or University (Click here to expand) School Name City, State Course of Study Years Completed 1 2 3 4 Did you Graduate? Yes No List diploma or degree: Employment History(past employment, internships and/or volunteer experience)Company 1 (Click here to expand) Company Name: Address: City: State: Zip: Telephone: Dates employed: Describe the work you did: Type (Employment, Internship or Volunteering): Company 2 (Click here to expand) Company Name: Address: City: State: Zip: Telephone: Dates employed: Describe the work you did: Type (Employment, Internship or Volunteering): Company 3 (Click here to expand) Company Name: Address: City: State: Zip: Telephone: Dates employed: Describe the work you did: Type (Employment, Internship or Volunteering): May we contact the employers above? Yes No If not, indicate which one(s) you do not wish us to contact? Personal References(Please do not use relatives)Reference 1 (Click here to expand) Name: Address: City: State: Zip: Telephone: Email: Reference 2 (Click here to expand) Name: Address: City: State: Zip: Telephone: Email: Reference 3 (Click here to expand) Name: Address: City: State: Zip: Telephone: Email: Applicant's Statement & Signature: I give Brook Lane permission 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. I agree to be photographed by Brook Lane. 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. In the event of resignation or dismissal, I agree to return all Brook Lane property loaned to me. Entering my name in the field below 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. Agree I have read and agree to the terms above (required for submission) Name:
