Name:

College/university:

Year:
Senior Junior Sophomore Graduate Graduate Student

Major:

Expected graduation date:

Minor:

Current Address:

Permanent Address:

Telephone: (Current)

Telephone: (Permanent)

Political affiliation:
Republican Democrat Other

Email Address:

Grade Point Average

College activities, honors, awards:

Government or political experience (employment, campaign volunteer work, etc.):

Areas of public policy interest (environment, education, health care, taxation, etc.):

What specialized skills do you have?

Writing sample

1.) Write an essay (200 words or less) on why you want to serve in the Senate intern program and what you hope to gain from this experience.

Work Experience

Employer Position:

Responsibilities:

Immediate supervisor:

Beginning date / Ending date:

Employer Position:

Responsibilities:

Immediate supervisor:

Beginning date / Ending date:

References

Name:

Address:

City:

Title:

Telephone:

Name:

Address:

City:

Title:

Telephone:

I certify that there are no misrepresentations or falsifications of these statements and answers. I am also aware that falsification of this application, or any accompanying data, may result in my dismissal from the Senate Intership Program.

Please send copy of grade transcript to: Amy Surber, Senate, State of Indiana, 200 W. Washington St., Room 126, Indianapolis, IN 46204-2785