Department Internship Information Form

SocA 491 (B)(C) "Professional Field Experience" 1-12 hours P/F

Date Date / MM / DD YYYY
Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Student ID *
Internship Provider Information

This is the description of your section break.
Org Name
Internship term - please indicate the year and semester:
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone * - ### - ### ####
Email *
Other Information

This is the description of your section break.
Multiple Choice *

Multiple Choice 1 Cr Hr = 45 total hours 2 Cr Hr = 90 total hours 3 Cr Hr = 135 total hours 4 Cr Hr = 180 total hours 5 Cr Hr = 225 total hours 6 Cr Hr = 270 total hours 7 Cr Hr = 315 total hours 8 Cr Hr = 360 total hours 9 Cr Hr = 405 total hours 10 Cr Hr = 450 total hours 11 Cr Hr = 495 total hours 12 Cr Hr = 540 total hours
DESCRIPTION OF DUTIES, JOB TASKS AND/OR EXPECTATIONS. (Please be specific. Information should be obtained through your
internship provider.) *
AGREED TO SCHEDULE (Please include: start date and end date, and if possible weekly schedule, days and times.) *