Last Name: _______________ First:_____________ MI:___

Class Year:_____________ Major:____________________

Phone Number: (____)______________________

Cell Phone (if Available): (____)_________________

E-Mail Address:___________________________________

Home Address:___________________________________

____________________________________

College Name:____________________________________

College Address:__________________________________

___________________________________

Professor’s Name:_________________________________

Professor’s Phone: (____)_________________________

What semester will you be available to start your internship?

(Circle One): Spring Summer Fall Winter

Part Time / Full Time internship? (Circle one):

Part Time (Min. of 16 hrs. a week)

Full Time (Min. of 40 hrs. a week)

Do you have any experience in the following? Camera, Editing, Graphics, Audio, Journalism, ect.? (Y or N): ______

If yes, Please explain:_______________________________

________________________________________________________________________________________________

________________________________________________

Thank you for your interest in an internship at WCTR-TV 3. Please fax back this appilcation form to Pam Larson, Intern Coordinator at (508) 854-5065. Or Mail it to WCTR-TV 3 Attn: Pam Larson 95 Higgins Street, Worcester, MA 01606. You will be contacted as soon as possible to set-up an interview. If you have any questions please call Pam Larson at (508) 853-1515 x.72221.