Maryland State Department of Education
Division of Rehabilitation Services
Intern/Volunteer Application
Mail to:
Human Resource Development Specialist
Division of Rehabilitation Services
2301 Argonne Dr., Baltimore, MD 21218
410-554-9381
TTY: 410-554-9411
FAX: 410-261-2940
Name:
Address:
Phone:
City: State: Zip: Email:
Emergency Contact:
Phone & Email:
Special Needs/Accommodations:
Educational Institution:
Internship Supervisor/University Professor:
Phone & Email:
Academic Program: Class:
Requested Academic Semester/Year: Total Hours Needed :
Goals of Internship:
Requested Schedule including days of the week and hours of availability:
DORS Office location preference for internship site:
(For locations please visit) www.dors.state.md.us
Have you ever been convicted of any violation of law other than minor traffic violations? Yes No
If yes, attach a page with the date, place of conviction, charge and disposition of each case. [NOTE: A conviction record will not necessarily bar you from an internship.]
Comments/Additional Information:
Applicant Signature:
Date:
Submit the DORS internship application and a current resume at least 4 weeks before the start of your semester. Assignments contingent upon DORS capacity; priority will be given to students in Masters programs in Rehabilitation Counseling.
Please attach your resume to this application.
Required DORS Signatures:
DORS Internship Site Supervisor Signature/date
Program Manager Signature/date
DORS HRD Specialist Signature/date
Volunteer Coordinator Signature/date
Assigned Internship Location:
The Maryland State Department of Education does not discriminate on the basis of race, color, sex, age, national origin, religion or disability in matters affecting employment or in providing access to programs.
MSDE-DORS-RS-9d: 03/10 Internship Application Page 1 of 2