Kenova Municipal Court Application Form Page 2
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1
2
3Kenova Municipal Court
1501 Pine Street
Kenova, WV 25530
(304) 453-2206
Fax: (304) 453-1601
Internship Program
Permanent Address: _____________________________________________________
______________________________________________________________________
Cell Phone Number: ____________ Permanent Phone Number: ___________
Email address: __________________________________________________________
Date of Birth: ____________ Place of birth: _______________________________
Number of hours required to earn credit hours: _____________________________
Institution granting credit hours: __________________________________________
Years attended: ___________ Major course of study: ____________________
List three references (not relatives) that have known you for at least two years:
Name:
Name:
Name:
______________________
______________________
______________________
Address:
Address:
Address:
______________________
______________________
______________________
City, State, Zip:
City, State, Zip:
City, State, Zip:
____________________
____________________
____________________
Telephone:
Telephone:
Telephone:
______________________
______________________
______________________
Occupation:
Occupation:
Occupation:
______________________
______________________
______________________
License number: _______________________
Have you ever been arrested for a felony offence? _______________
If yes, explain ___________________________________________________________
By signing this application, I attest that the information I have given is correct to the
best of my knowledge. By signing, I also give permission Kenova Municipal Court to
conduct a criminal background check in connection with my application to intern with
the court. I understand that any information obtained will be held in strict confidence.
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