Full Name     Age:

Address    City   State   Zip

Home Phone   Alternate Phone (cell)
Please include area code with your phone number(s)

E-mail  

Are you currently enrolled in school?  Yes   No 

School Name     Advisor 

Phone number for school advisor (include area code) 

Will you receive academic credit for this internship?  Yes    No

What period of the year would you like to do your internship?
Fall    Winter    Spring    Summer

Classification:  Freshman   Sophomore   Junior    Senior

Do you have a valid driver's license?  Yes   No

Do you have reliable transportation?  Yes    No

Do you have a clean driving record?  Yes   No

If not, please explain:

Please provide your Driver's License Number   and state

Have you ever been convicted of a crime?  Yes    No

If Yes, please explain:

Have you ever interned at another radio and / or television station?  Yes    No

If Yes, which station and where? 

Do you currently have a job (either full time or part time)?  Yes    No

If Yes, what is your job? 

Who is your Supervisor?  Supervisor's phone number

How did you hear about the Internship Program at Cumulus Media of Poughkeepsie?
WPDH   WRRV  MIX 97.7   94.3/97.3 THE WOLF  RADIO DISNEY  OTHER

Why do you want to intern with the Cumulus Media stations in Poughkeepsie?

The shifts for Interns are as follows.  Which shifts would you be available to work?

Are you available outside of the regularly scheduled intern shifts?  Yes    No

Do you understand that this internship is unpaid?  Yes    No