STUDENT INTERNSHIP APPLICATION

Please submit your application and current official college transcript to:
Richmond Police Department
 Internship Coordinator
Personnel & Recruitment
200 W. Grace Street
Richmond, VA 23220
Phone: 804-646-6733
Fax: 804-646-0405

PLEASE PRINT OR TYPE ALL INFORMATION ON THIS FORM

PERSONAL DATA

Last Name 
     	First                                  Middle
                                      	SSN
    -    -    	
School Address
     	
City
     	State
  	Zip Code
     	
Home Address
     	
City
     	State
  	Zip Code
        	
Telephone Number
(   )     -    	Alternate Telephone Number
(   )     -    	
Internship Position Name for which you are applying	     
     	
  Part-Time:  From 10 – 20 hours per week during the academic year	
  Full-Time:   From 30 – 40 hours per week	

EMPLOYMENT HISTORY

List work experience, beginning with the most recent position.

May we contact your present employer?  Yes	No

1.	
Employer
     		Address
     
	Telephone No.
(    )     -    	
Job Title
     	Supervisor
     	
Date Employed (Mo/Yr)
   /    	Date Separated (Mo/Yr)
   /    	Reason for Leaving
     	
Duties: 

     _____________________________________________________________________________________________________________
            _________________________________________________________
	_________________________________________________________
	_________________________________________________________

2.
Employer
     	Address
     	Telephone No.
(    )     -    	
Job Title
     	Supervisor
     	
		
Date Employed (Mo/Yr)
   /    	Date Separated (Mo/Yr)
   /    	Reason for Leaving
     	

Duties: 
     ___________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________ 

3.
Employer
     	Address
     	Telephone No.
(    )     -    	
Job Title
     	Supervisor
     	
Date Employed (Mo/Yr)
   /    	Date Separated (Mo/Yr)
   /    	Reason for Leaving
     	

Duties:   

     ___________________________________________________________________________________________________________________
____________________________________________________________
           ____________________________________________________________
           ____________________________________________________________		

Any mental or physical limitations in performing job-related functions, for which accommodations should be made?  Yes		 No

If yes, please describe:  

	     ________________________________________________________________________________________________________________________________________________________________________

It is the policy of the City of Richmond to hire those persons who are lawfully authorized to work in the United States. As a condition of employment, individuals hired by the City are required to present proof of identification and of their eligibility to work in the United States before they can begin work. Are you legally eligible for employment in the United States?
  Yes		 No

	

EDUCATION

IMPORTANT:  AN OFFICIAL COLLEGE TRANSCRIPT FROM YOUR CURRENT INSTITUTION MUST BE SUBMITTED WITH YOUR APPLICATION.

Beginning with your current institution, list chronologically all colleges/ universities attended since high school. EXPECTED GRADUATION DATE FROM YOUR CURRENT INSTITUTION MUST BE GIVEN.

Name of Institution
      	Major
     	
Location (City & State)
     	Expected Graduate Date
(Month & Year)
     	

Name of Institution
      	Major
     	
Location (City & State)
     	Expected Graduate Date
(Month & Year)
     	

The following section is to be completed by Academic Advisor at current college or university.

Student’s Name (Last)
     	(First)
     	(Middle)
     	(SSN)
    -   -    	
Major
     	Degree
     	
 Hours Completed 
     	Overall GPA 
     	

Class Status (Check One):	Freshman 	Sophomore       Junior     	Senior 
			             Graduate Program 

Would you recommend above named student?  Yes	 No
(If no, explain)      _______________________________________________________________________________________________________________________________________________________________________

(Advisor’s Signature & Date)
     	(Telephone Number)
          	
(Street Address)
     	(City/State)
     	(Zip Code)
     	

REFERENCES – List individuals familiar with your capabilities. Do not list relatives or supervisors previously noted under employment.

Name
     	Title                        Phone 
     	
Relationship                                                       Email address 
     	
Street Address & City/State
     		Zip Code
     	

Name
     	Title                         Phone
     	
Relationship                                                       Email address
     	
Street Address & City/State
     		Zip Code
     	

Name
     	Title                         Phone
     	
Relationship                                                       Email address
     	
Street Address & City/State
     		Zip Code
     	

SKILLS/EXPERIENCE – Please be specific about skills with computers, laboratory and other equipment.

Driver’s License:  Yes   No   	

  Computer Programming      ______________________________

  Computer Software Usage      _____________________________

 Laboratory/Other Equipment      ___________________________

DISTINCTIONS, HONORS AWARDS & OTHER RECOGNITION OF ACHIEVEMENTS

Please indicate the basis of selection and date for each listing.

     _______________________________________________________________________________________________________________
____________________________________________________________
           ____________________________________________________________

I hereby declare that the information provided by me in this application is true, correct, and complete to the best of my knowledge. 

Applicant’s Signature

     	Date:	

STUDENT INTERNSHIP
CONFIDENTIAL APPLICANT DATA SHEET

All responses are completely voluntary and will be used for statistical purposes only. The information will not be used in the employment process and will not become a part of your application. Refusal to respond will not result in adverse treatment of any applicant.

We would appreciate your completing the following:

(Last Name)
     	(First Name)
     	(Middle Name)
     	

(Internship Position Number for which you are applying)       
	
(Department)       

Race:	 White/Non-Hispanic Origin	Sex:	 Male	 Female

	 Black/Non-Hispanic Origin		Birth Date:	      (Month/Day/Year)

	 Hispanic

	 American Indian or Alaska Native

	 Asian or Pacific Islander

					

LIABILITY EXEMPTION

RICHMOND POLICE DEPARTMENT
RICHMOND, VIRGINIA

Date:	     	

I hereby release the City of Richmond, Virginia and any member of the Richmond Police Department from any and all liability directly or indirectly arising out of my riding in a police unit with a police officer of the City of Richmond, Virginia.

Signature:		

Witnesses: