APPLICATION FOR SENIOR INTERNSHIP

EXPECTED SEMESTER FOR: INTERNSHIP GRADUATION

NAME

STUDENT NUMBER - - OVERALL GPA

PRESENT ADDRESS

PRACTICUM HOME ADDRESS

PHONE NUMBER ( ) EMAIL

PRACTICUM LOCATION NAME ( )

ADDRESS

PRACTICUM PHONE NUMBER ( ) FAX

ON-SITE SUPERVISOR

NUMBER OF CREDITS (6-12)

DATES: START ON / / COMPLETE ON / /

BRIEF DESCRIPTION OF INTERNSHIP:

LIST OF OBJECTIVES:

LIABILITY INSURANCE YES NO