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L 02/04 APPLICATION FOR STUDENT INTERNSHIP PRINT OR TYPE SOCIAL SECURITY NO. (for identification purposes only) DATE DATE OF BIRTH (for identification purposes only) (Middle) (First) NAME (Last) (City, State, Zip Code) CURRENT ADDRESS (Street, HCR, Route Number) ALTERNATE TELEPHONE NUMBER TELEPHONE NUMBER E-MAIL ADDRESS HAVE YOU EVER BEEN CONVICTED OF A CRIME OTHER THAN A TRAFFIC VIOLATION? YES NO IF YES, EXPLAIN HAVE YOU EVER BEEN TERMINATED (OR ASKED TO RESIGN) FROM A JOB? YES N.

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