Name 
Campus Address 
Permanent Address 
Telephone 
Email Address 
Date 

The following information must be met as part of the UWMC Internship:
1. Minimum cumulative 2.0 GPA
2. Sophomore Standing
3. Enrollment in Lec 200 University Forum
4. Completion of the following information:

Career interest:

College/university credits completed 
Number of credits enrolled for semester 
Is there a limited distance you are able to travel to a work site? YesNo
 If yes, please explain

Extracurricular/volunteer activities involved

Previous employment experience:
Employer Position
Employer Position

Are you currently employed? YesNoHours per week
Internship interest area

Why are you interested in this internship program?