Internship Application

47 Broad Avenue Binghamton, NY 13904
Phone (607) 771-8888
Fax (607) 771-8892

Mental Health Association of the Southern Tier, Inc.

47 Broad Avenue, Binghamton NY 13904
Phone: (607) 771-8888
Fax: (607) 771-8892

Name*:

Date of Application*:

Date of Birth: (optional)

Sex: Female Male

Email Address*:

Current Address*:

City*:

State*:

Zip Code*:

Current Phone Number*:

Is current address same as permanent address? Yes No

Permanent Address:

City*:

State*:

Zip Code*:

Permanent Phone Number:

Are you presently in school? Yes No

Where?

Major/Minor:

Credit Hours Completed:

Is this internship fulfill a course requirement? Yes No

Internship Semester:

Dates of Expected Internship:

Hours needed for your internship:

Type of Internship you would like:

Accounting Clerical Care Management Client Services Personnel Family Services: Fundraising Children Services Wellness Center

Are you planning on continuing to volunteer after the requirement is fulfilled? Yes No

Please list your current and/or previous educational experiences, listing your most recent experience first:

Criminal History

Have you ever been arrested? Yes No

If “Yes” how many times and explain:

Have you ever been convicted of a crime? Yes No

If yes, explain:

Do you give us permission to check this information? Yes No

Personal Information

Why are you interested in an internship atthe MHA?

What experiences, hobbies, or specialized skills do you have which might be helpful for work as an intern at the MHA?

With what service or community groups are you affiliated?

How did you learn about the MHA?

References

Please list three local references who we may contact.

Reference #1:

Name:

Phone:

Address:

Occupation:

Place of Employment:

Relationship:

How long have you known this person?

Reference #2:

Name:

Phone:

Address:

Occupation:

Place of Employment:

Relationship:

How long have you known this person?

Reference #3:

Name:

Phone:

Address:

Occupation:

Place of Employment:

Relationship:

How long have you known this person?

Emergency Contact

Emergency contact person:

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Relationship:

Certification

I hereby certify that the information on this application is accurate and complete to the best of my knowledge:

By the applicant entering their name in the box below, they are electronically signing this application and it carries the same legal value as if it were signed by the applicant in person.

Applicant Name / Electronic Signature*:

Date of Application*: