Department of Political Science/Ray C. Bliss Institute of Applied Politics
Congratulations on your decision to include an internship as a part of your academic experience. Fill out this
application form. You will be asked about your preference for where you will be for your internship and the type of
internship you want to pursue.
Student Information
Name ___________________________________________________________________________
Address _______________________________ City _________________, OH Zip ________
Cell or school phone ___________________________ Second phone ________________________
UA e-mail _________________ Alternate e-mail ______________ Student ID # ________________
Signature (by signing you are aware that this an academic course, with assignments and tuition)
_____________________________________________________________________________
Who should we contact in case of an emergency:
Name ___________________________________________ Relationship _____________________
Address _______________________________ City ________________ State _____ Zip ________
Phone _______________________________
Alternate phone ____________________________
Academic Information
Class Rank (circle): Graduate Senior Junior Sophomore Freshman Credits Completed ______
Overall GPA _______ Political Science credits completed ______ Pol. Sci. GPA __________
Major (circle): MAP MA – Pol. Sci. BA - Pol. Sci. BS – Pol. Sci./CJ Other __________________
Party Affiliation (circle): Democrat
Republican
Independent Don’t Know
Other ___________
In what semester would you like to complete your internship?_________________________________
Internship Information
Check the area you are interested in for your internship (check all that apply):
_____ Applied Politics
_____ Legislative/Policy/Public Admin
____ Non-profit organizations
_____ Conflict Management
_____ International Relations
_____ Criminal Justice
_____ Federal law enforcement
Credit Hours
Work Hours
Average Per Week
Change
9
540
36
**
8
465
31
**
7
390
26
**
6
315
21
***
5
240
16
***
4
165
11
***
3
90
6
***
2
60
4
***
*** Hours will change for Summer Semester
***Hours per week will change in Summer Semester