Internship Application for McLaren Medical Group

Note: Fields marked with an * indicates required field

First Name: *

Middle Initial: *

Last Name: *

E-mail Address: *

Address: *

City: *

State: *

Zip Code: *

Home or Cell Phone: *

In case of emergency, contact - include name and phone: *

Relationship to Emergency Contact: *

Have you ever worked for McLaren Health Care or its affiliates, directly or through an agency or as a contractor? *

yesno

If yes, please provide location, and last month/year worked: *

Are you currently attending school? *

yesno

Please list school or university: *

Please choose the type of internship you are interested in *

Are you applying to intern to meet an academic requirement? *

yesno

School Placement Coordinator/Counselor Name: *

School Placement Coordinator or Counselor Phone Number: *

Which department/areas are you interested in? *

If known, which department and supervisor will you be interning with? *

What is the length of the internship? *

Have you ever been convicted of a felony? *

yesno

If yes, please explain and provide dates, location, results, fines paid or time served: *

Have you ever been convicted of a misdemeanor, or any other criminal offence, excluding minor traffic violations? *

yesno

If yes, please explain and provide dates, location, results, fines paid or time served: *

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