PROJECT LONGEVITY INTERNSHIP ONLINE APPLICATION
First Name: *
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Last Name: *
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Date of Birth: *
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Gender: *
Physical Street Address: *
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City: *
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State: *
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ZIP Code: *
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Cell Phone: *
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E-Mail Address: *
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In the event of an emergency, list a relative or close associate who can be contacted: *
Enter: name, relationship and phone number.
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Name of Academic Institution: *
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Last Academic Year Completed: *
Academic Major *
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Organization Memberships List any organizations, associations, or community groups to which you belong:
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Provide a statement, not to exceed two paragraphs, describing the reasons you believe you are a good candidate for the Project Longevity internship program. *
Include your involvement and/or membership in any civic, religious, business, and/or community organizations highlighting your contributions to the community.
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Criminal Background Information *
Have you ever been charged with or convicted of any felony offense?
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If yes, provide details, including date, place, law enforcement agency, charge, court, and disposition.
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How did you hear about Project Longevity? *
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