Kentucky City/County Internship Application Form

Skip any line that you cannot answer/ does not apply

* Student’s Name

Address

City

State

Zip Code

Cell Phone Number

Home Phone Number

University

* E-mail Address

Program/Major (undergraduate)

Concentration (undergraduate) (optional)

Anticipated Graduation Date

Current Job/Position

Title of Job/Position

Please list your relevant experiences

Please list what you would like to gain/ learn from an internship with a Kentucky city/county

Is there a certain area of the State where you would like to do an internship?

Yes
No

If yes, where?

Please list one faculty advisor contact/reference

Name

E-mail Address

Phone Number

I acknowledge that KCCMA will distribute this information and application form to some or all the members of the Association to facilitate the finding of an internship for the student. I hereby authorize the release of this information/application.

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