CRCJ Internship Practicum Application
Department of Criminology and Criminal Justice
Name
Name
*
First
Last
UTA ID Number
*
UTA Email
*
Phone
Phone
*
-
###
-
###
####
Current Cumulative GPA
*
CRCJ GPA
*
Total number of hours completed (by transfer and in residence at UTA) by the end of this present semester:
*
Anticipated semester of graduation:
*
Number of hours for which you will enroll in CRCJ 4390 (special permission required for 6 hours):
*
If working another job, number of hours per week required:
*
Will you structure your class schedule to be able to devote one day per week to the internship (not required, but preferable for the best experience)?
*
Will you structure your class schedule to be able to devote one day per week to the internship (not required, but preferable for the best experience)?
Yes
No
Number of CRCJ course completed at UTA and all other institutions:
*
List CRCJ courses, by course number, completed at UTA:
*
Do you have transportation to the work site?
*
Do you have transportation to the work site?
Yes
No
Do you have medical and automobile insurance?
*
Do you have medical and automobile insurance?
Yes
No
Do you have any health issues that will need to be taken into consideration?
*
Do you have any health issues that will need to be taken into consideration?
Yes
No
If yes, please explain.
Do you consent to a background investigation if one is required by the internship agency/organization?
*
Do you consent to a background investigation if one is required by the internship agency/organization?
Yes
No
Semester and agency with which you want to do the internship:
*
Draw your signature into the box below.
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Type
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Clear
Full Name
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Date
Date
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