+---------------------------+-----+-----+----------------------------+
| ## Pleas                  | #   |     |                            |
| e complete and return to: | # A |     |                            |
|                           | ppl |     |                            |
| ##                        | ica |     |                            |
|                           | tio |     |                            |
| ## ATTN: I                | n C |     |                            |
| ntern Coordinator Fax: (2 | hec |     |                            |
| 02) 228-1265 Email: [**in | kli |     |                            |
| ternships@brownback.senat | st: |     |                            |
| e.gov**](mailto:internshi |     |     |                            |
| ps@brownback.senate.gov)  | ##  |     |                            |
|                           |   C |     |                            |
|                           | omp |     |                            |
|                           | let |     |                            |
|                           | ed  |     |                            |
|                           | Con |     |                            |
|                           | gre |     |                            |
|                           | ssi |     |                            |
|                           | ona |     |                            |
|                           | l I |     |                            |
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|                           | rns |     |                            |
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|                           |  Ap |     |                            |
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|                           | cat |     |                            |
|                           | ion |     |                            |
|                           |     |     |                            |
|                           | ##  |     |                            |
|                           |   C |     |                            |
|                           | urr |     |                            |
|                           | ent |     |                            |
|                           |  Re |     |                            |
|                           | sum |     |                            |
|                           | e   |     |                            |
|                           | Two |     |                            |
|                           |  Le |     |                            |
|                           | tte |     |                            |
|                           | rs  |     |                            |
|                           | of  |     |                            |
|                           | Rec |     |                            |
|                           | omm |     |                            |
|                           | end |     |                            |
|                           | ati |     |                            |
|                           | on  |     |                            |
|                           |     |     |                            |
|                           | ##  |     |                            |
|                           |  1- |     |                            |
|                           | pag |     |                            |
|                           | e E |     |                            |
|                           | ssa |     |                            |
|                           | y   |     |                            |
|                           | Sig |     |                            |
|                           | ned |     |                            |
|                           |  an |     |                            |
|                           | d D |     |                            |
|                           | ate |     |                            |
|                           | d R |     |                            |
|                           | ule |     |                            |
|                           | s C |     |                            |
|                           | ons |     |                            |
|                           | ent |     |                            |
|                           |  Fo |     |                            |
|                           | rm  |     |                            |
|                           |     |     |                            |
|                           | ##  |     |                            |
|                           |   A |     |                            |
|                           | ddi |     |                            |
|                           | tio |     |                            |
|                           | nal |     |                            |
|                           |  Wr |     |                            |
|                           | iti |     |                            |
|                           | ng  |     |                            |
|                           | Sam |     |                            |
|                           | ple |     |                            |
|                           |  (O |     |                            |
|                           | pti |     |                            |
|                           | ona |     |                            |
|                           | l)  |     |                            |
+---------------------------+-----+-----+----------------------------+
| ##                        |     |     |                            |
|  BIOGRAPHICAL INFORMATION |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| Name:                     |     | #   |                            |
|                           |     | # C |                            |
|                           |     | urr |                            |
|                           |     | ent |                            |
|                           |     |  Ad |                            |
|                           |     | dre |                            |
|                           |     | ss: |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## Soci                   |     | ##  |                            |
| al Security Number:       |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## Date of Birth:         |     | ##  |                            |
|                           |     | Per |                            |
|                           |     | man |                            |
|                           |     | ent |                            |
|                           |     |  Ad |                            |
|                           |     | dre |                            |
|                           |     | ss: |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## Gender:  Male  Female  |     | ##  |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ##                        |     | ##  |                            |
| College/University:       |     |  Sp |                            |
|                           |     | eci |                            |
|                           |     | fic |                            |
|                           |     |  is |                            |
|                           |     | sue |                            |
|                           |     | s a |                            |
|                           |     | rea |                            |
|                           |     | s o |                            |
|                           |     | f i |                            |
|                           |     | nte |                            |
|                           |     | res |                            |
|                           |     | t t |                            |
|                           |     | o y |                            |
|                           |     | ou: |                            |
|                           |     |     |                            |
|                           |     |     |                            |
|                           |     |     |                            |
|                           |     | ##  |                            |
|                           |     |     |                            |
|                           |     | ##  |                            |
|                           |     |     |                            |
|                           |     | ##  |                            |
|                           |     |     |                            |
|                           |     | ##  |                            |
+---------------------------+-----+-----+----------------------------+
| ## Year in School:        |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## Primar                 |     |     |                            |
| y Telephone Number:       |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## Secondar               |     |     |                            |
| y Telephone Number:       |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## E-mail:                |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## De                     |     | ##  |                            |
| sired Internship Session: |     | App |                            |
|                           |     | lic |                            |
| ##  Spring                |     | abl |                            |
| Session (January -- May)  |     | e s |                            |
|                           |     | kil |                            |
| ##  Summer                |     | ls: |                            |
|  Session I (May -- June)  |     |     |                            |
|                           |     |     |                            |
| ##  Summer Ses            |     |     |                            |
| sion II (July -- August)  |     | ##  |                            |
|                           |     |     |                            |
| ##  Fall Sessio           |     | ##  |                            |
| n (September -- December) |     |     |                            |
|                           |     | ##  |                            |
+---------------------------+-----+-----+----------------------------+
| ## ACADEMIC INFORMATION   |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| Do you seek academic      |     |     | ## Advisor's Name:         |
| credit for this           |     |     |                            |
| internship: Yes No        |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| Academic Major(s):        |     |     | ## Daytime Phone:          |
+---------------------------+-----+-----+----------------------------+
| GPA:                      |     |     | ## E-mail:                 |
+---------------------------+-----+-----+----------------------------+
| ##                        |     |     |                            |
|  OCCUPATIONAL INFORMATION |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| Work or volunteer         |     | ##  |                            |
| experience                |     |  Ac |                            |
|                           |     | tiv |                            |
| (beginning with the most  |     | iti |                            |
| recent):                  |     | es: |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ##                        |     | ##  |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ##                        |     | ##  |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ##                        |     | ##  |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## REFERENCES             |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| Please list 2 individuals |     |     |                            |
| who will be writing your  |     |     |                            |
| letters of recommendation |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## Academic Reference     |     | ##  |                            |
|                           |     | Cha |                            |
|                           |     | rac |                            |
|                           |     | ter |                            |
|                           |     |  Re |                            |
|                           |     | fer |                            |
|                           |     | enc |                            |
|                           |     | e ( |                            |
|                           |     | com |                            |
|                           |     | mun |                            |
|                           |     | ity |                            |
|                           |     | /vo |                            |
|                           |     | lun |                            |
|                           |     | tee |                            |
|                           |     | r/w |                            |
|                           |     | ork |                            |
|                           |     | /ac |                            |
|                           |     | tiv |                            |
|                           |     | ity |                            |
|                           |     |  re |                            |
|                           |     | lat |                            |
|                           |     | ed) |                            |
+---------------------------+-----+-----+----------------------------+
| ## Name:                  |     | ##  |                            |
|                           |     |  Na |                            |
|                           |     | me: |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## Title:                 |     | ##  |                            |
|                           |     | Tit |                            |
|                           |     | le: |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## Address:               |     | ##  |                            |
|                           |     |  Ad |                            |
|                           |     | dre |                            |
|                           |     | ss: |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ##                        |     | ##  |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| #                         |     | ##  |                            |
| # Telephone Number:       |     |  Te |                            |
|                           |     | lep |                            |
|                           |     | hon |                            |
|                           |     | e n |                            |
|                           |     | umb |                            |
|                           |     | er: |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## E-mail:                |     | #   |                            |
|                           |     | # E |                            |
|                           |     | -ma |                            |
|                           |     | il: |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## *Please a              |     |     |                            |
| ttach two letters of reco |     |     |                            |
| mmendation and submit wit |     |     |                            |
| h application materials.* |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## PA                     |     |     |                            |
| RENT/GUARDIAN INFORMATION |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## Name:                  |     | ##  |                            |
|                           |     | Nam |                            |
|                           |     | e:  |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## Occupation:            |     | ##  |                            |
|                           |     |  Oc |                            |
|                           |     | cup |                            |
|                           |     | ati |                            |
|                           |     | on: |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## Address:               |     | ##  |                            |
|                           |     |  Ad |                            |
|                           |     | dre |                            |
|                           |     | ss: |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ##                        |     | ##  |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ##                        |     | ##  |                            |
|  Telephone Number:        |     |  Te |                            |
|                           |     | lep |                            |
|                           |     | hon |                            |
|                           |     | e n |                            |
|                           |     | umb |                            |
|                           |     | er: |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## E-mail:                |     | #   |                            |
|                           |     | # E |                            |
|                           |     | -ma |                            |
|                           |     | il: |                            |
|                           |     |     |                            |
|                           |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| #                         |     |     |                            |
| # *Please include a curre |     |     |                            |
| nt resume and a one-page  |     |     |                            |
| essay detailing your inte |     |     |                            |
| rest in appointment in th |     |     |                            |
| is internship. [One]{.und |     |     |                            |
| erline} additional writin |     |     |                            |
| g sample may be sent for  |     |     |                            |
| consideration at the disc |     |     |                            |
| retion of the applicant.* |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## CONGRESSIONAL RULE     |     |     |                            |
| S AND REGULATIONS CONSENT |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## If select              |     |     |                            |
| ed, I hereby agree to abi |     |     |                            |
| de by the rules and regul |     |     |                            |
| ations for congressional  |     |     |                            |
| employees and the office  |     |     |                            |
| of Senator Sam Brownback. |     |     |                            |
+---------------------------+-----+-----+----------------------------+
| ##                        | ##  |     |                            |
+---------------------------+-----+-----+----------------------------+
| ## Signature of Applicant | #   |     |                            |
|                           | # D |     |                            |
|                           | ate |     |                            |
+---------------------------+-----+-----+----------------------------+