Internship Application Form

PLEASE TYPE OR PRINT LEGIBLY

Please check the office(s) for which you would like to intern:

Lincoln, NE: ______ Omaha, NE: ______ Washington, DC: ______

Please check the session for which you are applying:

Spring Session (January – May): ________

Summer First Session (May - June): ________

Summer Second Session (July - August): ________

Fall Session (September - December): ________

As best as you can, please note on what days and at what times you are available:

_________________________________________________________________

PERSONAL INFORMATION

Full name: __________________________________  Today’s Date:___________

Social Security Number: ______-____-______ Date of birth: __________________

Place of Birth: ___________________________ (City/State and Country if not USA)

E:Mail: ____________________________________________________________

Permanent Phone: __________________ School Phone: _____________________

Cell Phone: _________________________ Work Phone: _____________________

Are you registered to vote? _____ yes _____ no  What state: _________________

Prior Campaign/Political/Experience: _____________________________________

__________________________________________________________________

Areas of Interest: ____________________________________________________

__________________________________________________________________

ACADEMIC INFORMATION

College/University: __________________________________________________

Year in School: _________________  Year of Graduation: ___________________

GPA: _____________________ Major: __________________________________

Are you receiving or do you plan to receive academic credit for your internship?

Yes: ________ No: ________ Not sure: ________

SECURITY QUESTIONS

Have any disciplinary or administrative actions (probation, suspension, expulsion) been taken against you by your school or are any pending?

Yes: ________ No: ________

Have you ever been charged with or convicted of any criminal offense, DWI, drug or misdemeanor offense?

Yes: ________ No: ________

If you answered yes, please explain using a separate piece of paper.

CERTIFICATION

My statements on this form and any attachments to it are true, complete and correct to the best of my knowledge and made in good faith. I understand that knowingly false answers will lead to the rejection of my application or immediate dismissal from the program.

Signature: _____________________________________  Date: _____________