Name:

Current address:

City: State: ZIP code:

Home phone number: Cell phone number:

E-mail address:

Gender

Male

Female

Academic institution attending:

Degree working on/program:

Year in program

Junior

Senior

Other:

Faculty advisor/University contact name:

Advisor e-mail address:

Advisor phone number:

Advisor street address:

City: State: ZIP code:

Is an internship, service learning experience, observation or rotation required for your degree?

Yes

No

Are you interested in an internship, service learning experience, or observation/rotation?

Internship:

Service learning experience:

Observation/rotation:

Number of hours required?

Anticipated starting and ending dates of internship/observation/rotation/service-learning experience:

until

Program of interest (Please select at least one)

Administration

Clinical Services

Communicable Disease

Community Health Planning

Dental Services/Dental Hygiene

Emergency/Disaster Preparedness

Environmental Health

Epidemiology

Fiscal Services

Health Education/Promotion

HIV Case Management

Home Visiting Services

Human Resources

Nutrition Services

Public Information (Media, communications)

Residency

Support Services (Clerical, medical records)

Other:

I am interested in this opportunity because (i.e., what I hope to gain):

I am a great candidate for this opportunity because (i.e. knowledge, skills, experience):

Current degrees/licensures:

My resume is attached: Yes No

Attach resume file here:

Date application completed: