Thank you for considering CenClear for your Internship/Supervision experience. Prior to participating in an Internship/Supervision at CenClear you will be required to have obtain the following clearances:

· PA Criminal Record (State Police)-
· Child Abuse History Check-
· FBI Clearance- PA Department of Human Services - · Mandated Reporting

Please answer the questions thoroughly. If a question does not apply to your request please write N/A in the answer box.

First Name*:
Last Name*:
Phone Number*:
Department you wish to complete an Internship/Supervision in:
Date of Internship/Supervision Required/Requested*:
Number of Hours Required (if no requirements, please list N/A)*:
Supervision Requirements: (If no requirements, please list N/A)*:
Degree You Are Working to Obtain and Concentration: (If you are not working towards a degree, please note that.)*:
Have you ever worked for CenClear before*:
If you answered "yes" to question 11, please indicate the position you held with CenClear and the dates you worked for us.:
Name, phone number and email address of School Contact Person, if applicable::