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COM 471/472 COM Studies Internship Application

Name: ________________________________________ ID#: __________________

Address: _____________________________________ City: _____________ State: _____

Phone #’s: ________________________________ e-mail: _________________________

Major& # of credits: ___________________Minor: _________________ GPA(overall): _______

Driver’s License # & State issued: __________________________________________________

Name of Insurance Carrier:_______________________________________________________

Internship Site and Complete Address: ______________________________________________

____________________________________________________________________________

Internship Supervisor’s NAME, TITLE, PHONE #, FAX #, E-MAIL:

_____________________________________________________________________________

_____________________________________________________________________________

# of credits wanted (1-6 credits) at 40-45hrs. per credit: _______________
(1cr.=40-45hrs, 2cr.=80-90hrs, 3cr.=120-135hrs, etc.)

NOTE & SIGNATURE: If, after consulting with the intern & the internship supervisor, there is any reason that the internship experience isn’t working to the agreed upon expectations, Sharman Brown may terminate my internship experience. Also, I understand that IF Sharman Brown doesn’t hear from me via e-mail after the first two weeks of working at your site she has the right to DROP me from my Internship.

Signature: ________________________________________ Date: _______________

To Be Completed by Sharman Brown, Internship Coordinator

# of credits approved: ______________= _________________________hrs.

Signature: _____________________________ Date: _____________

Start Date: ______________ Finish Date: _____________