This form is to be completed and filed with the course professor prior to beginning an internship. Any student who furnishes false information will be subject to possible disciplinary action.
Some agencies require a character and criminal record check prior to accepting an intern.
Submission of this application gives the agency your expressed consent to a background check if the agency deems this necessary or appropriate. The following information is required to assist in such an investigation and serve as a record for your internship. It is understood by both parties that the information contained in this application is confidential and to be used only for the purpose of placement in an internship agency. Social Security No. Start with present or last employer first.