Name First Middle Last Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneSocial Security #NCDL #Place of BirthGeneral InformationCollege / University currently attendingMajorInternship PreferencePositionLocationPopulation of InterestAdult Mental HealthAdult Substance UseChild Mental HealthChild Substance UseInternship LevelUndergraduateGraduateWhen does your internship start?When does your internship end?How many internship hours do you need to complete?College / University Contact InformationNameTitleDo you know, or are related to any individuals currently employed or contracted by PORT Human Services?If yes, Please indicate namesThe State of North Carolina requires that a criminal record background check and health care registry check be conducted on all prospective Interns prior to the start of an internship in the human services field. Have you ever been convicted of child abuse or neglect or any other criminal offense, or forfeited a bond?(Note: A conviction will not necessarily exclude you from consideration for internship. Factors such as age at the times of offense, rehabilitation efforts, how recent the offense was, nature of the crime and type of job you are applying for will be considered.) If yes, Please explainDescribe what qualities you feel you would add to our organization?What professional growth goals will be addressed with this internship?Please read the following statements carefully and submit: I certify that the information I have provided accurately represents my background and that any false or incomplete information will be grounds for rejection of my application or dismissal from internship program at PORT Health Services. I authorize PORT Human Services to obtain information about me from contact information regarding institutions listed on this application. I understand any internship position I am offered is contingent upon receipt of a State Criminal Record check. The company may rescind any offer for internship placement based on the contents of this document. I acknowledge that this an internship placement application and not an internship agreement.