Internship Application Form

Please complete this form and upload your cover letter, resume, and unofficial transcripts.
GENERAL INFORMATION
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
SCHOOL INFORMATION
Please indicate the school you are currently enrolled in, the type of degree program, and your major in the spaces below.
School Name
This is a
- Graduate
- Undergraduate
- Other – Professional Degree Program
Availability: Start Date*
MM slash DD slash YYYY

Given PBIL’s internships are offered throughout the year, enter the start date of when you would be available to begin an internship.
Availability: End Date*
MM slash DD slash YYYY

Given PBIL’s internships are offered throughout the year, enter the date of when you would no longer be available to intern with IDPH.
Academic Program (Major):*
Required Number of Internship/Practicum Hours to Satisfy Academic Requirements
Name of Internship Faculty Coordinator:
Faculty Coordinator Email Address:
Estimated Graduation Date:
MM slash DD slash YYYY

Please note that your submitted data will be deleted after your program completion date, as you will no longer be eligible for an internship position.
INTERNSHIP PREFERENCES
Desired Work Site
- Primarily Remote
- Remote plus 1 day/week in PBIL Office
Desired Location(s)
- I am able to conduct events in Chicago suburb areas Y/N
- I am able to conduct events or meetings statewide if a travel stipend is provided Y/N
Mode of Transportation
- I have my own vehicle
- I rely on public transportation
Hours available weekly
Anticipated work schedule
- Weekdays only
- Weekends only
- Weekdays and Weekends
File Attachments (please read requirements carefully)*
Drop files here or
Max. file size: 100 MB.
Upload your cover letter, resume and unofficial transcripts.
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Internship Application Form