Application Form

Michigan State University

Internship/Cooperative Education Application Form

Applying for:

Internship

Co-op

Semester: Year:
Anticipated Graduation Date:
Credits Requested:

Standing:

Junior

Senior

Graduate

Program Track:
Criminal Justice Program
Forensic Science Program

Name:
E-Mail address:
Date of Birth: Student ID #: Soc. Sec. #:
Driver's License #: State Issued:

Any Convictions:: Felony: Yes No; Misdemeanor: Yes No

If yes, what:

Own Transportation: Yes No

U.S. Citizen: Yes No

Local/Office Address:

Number/Street: Apt:
City: State: Zip:
Phone: ( )

Home Address:

Number/Street: Apt:
City: State: Zip:
Phone: ( )

FOR ADVISOR USE ONLY:	Initials	Date:
Total No. of credits approved:	CJ 494:	CJ 894:
Total credits completed to date:	CJ GPA:	Cumulative GPA:

Core Courses completed to date:

110

220

292

335

355

365

375

Internship/Co-op Terms

I understand that CJ 494/894 is a graded on a "Pass/No Credit" basis. Receiving a "No Credit" grade in the internship could result from one or more of the following circumstances:
- termination of the internship by the agency supervisor
- violation of professional ethics
- failure to meet academic requirements and deadlines
I understand that if I terminate placement after processing has begun, further applications may not be accepted.
I give permission for the above information to be released to approved criminal justice internship agencies.

I accept.

I do not accept.

Law Enforcement	Juvenile Delinquency	Forensic Science
Corrections	Security Administration	Federal Agencies
Pre-Law	Probation/Parole	No Preference

Why did you choose to pursue this area of criminal justice?
What skills or talents will you bring to this field?
What do you want to gain from an internship?
Within what geographic area would you like to intern?

Students must coordinate approval with their academic advisor and submit this form to the internship placement coordinator. Students should also choose 3 to 6 agencies they might like to intern with by reading the position descriptions available in 535 Baker or on the World Wide Web at: http://www.cj.msu.edu/~career/index.html.

Internship and Cooperative Education Insurance and Liability Form

No Criminal Justice Internship/Cooperative Education agency assumes liability for injury the student might sustain while participating in the internship/cooperative education program.
Unless you are already covered by a health insurance policy, you will be expected to sign up for the student health insurance policy offered through MSU.
It is the responsibility of the individual student to work out the details and requirements for the student health insurance policy. Contact Olin Health Center at 517-355-4510. For assistance, contact the Chickering Group at 1-800-859-8452 or MSU Benefits at 517-353-4434 ext. 536.

I certify that I have read the information above and that I have subscribed to the MSU student health insurance policy or possess coverage of another insurance policy offering equal coverage. I waive the right to submit a claim to Michigan State University or any criminal justice internship/cooperative education agency as a result of injuries or illness sustained while participating in the Criminal Justice Internship/Cooperative Education Program.

Students who furnish false information on this form will be subject to disciplinary action, including possible dismissal from the Criminal Justice Internship/Cooperative Education Program.

Name of Insurance Company:
Policy Number:

I accept.

I do not accept.

This form will be sent to the internship coordinator.

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