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Undergraduate Internship Application

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EDINBORO UNIVERSITY OF PENNSYLVANIA

APPLICATION FOR PERMISSION TO REGISTER FOR AN UNDERGRADUATE INTERNSHIP

This is the official application form for requesting authorization to register* for an Edinboro University of Pennsylvania approved internship. No other application form for internship is valid. After the student receives the copy of the application showing the internship has been approved, the STUDENT must pay the fees at the Bursar’s Office, then contact the Scheduling Office to complete registration for the internship. REGISTRATION MUST BE COMPLETED PRIOR TO THE PROJECTED BEGINNING DATE OF THE INTERNSHIP.

A typed one to three-page description of the professional experiences and educational outcomes (daily logs, major paper or project, portfolio, detailed oral report, etc.) that the applicant is to undertake must be attached before submitting this form for approval.


I. EDUCATIONAL DATA (To be typed by student) Top of Form

Name


Last

 

 

Student Identification Number

First

 

 

Student E-mail Address

M.I.

 

 

 

 

 


Address during Internship

Street

 

 

 

City

 

 

 

State

 

 

Zip

 


Home Address (if other than above)

Street

 

 

 

City

 

 

 

State

 

 

Zip

Home Phone

 

 

 

 

Major Field

 

 

Major GPA

 

 

 

 

Undergraduate GPA

 

 

 

 

Anticipated Graduation Date

 


II. INTERNSHIP DATA

1st Semester 20 2nd Semester 20 Summer Session 20

Course Number

 

Course Title

 

Number of Credits

 

Proposed Site Supervisor

 

Site Supervisor  Phone

 

Internship Site

 

 

 

Internship Site Address

Street

 

 

 

City

 

 

 

State

 

 

Zip

 

 

Internship Period (Month/Day/Year)

Starts

 

 

Ends

 

 

Number of Weeks

 

 

Hours per Week

 

 

Daily from

 

 

to

 

Paid

 

 

 

 

Nonpaid

 

 

 

Hourly Amount

 

 

 

Student’s phone on site

 

 

 


III. INTERNSHIP APPROVAL (The following SIGNATURES must be obtained in sequence; copies will be sent to all signers)


_________________________________________________
Student's Signature

 

_______________________
Date

 

 

 

_________________________________________________
Advisor’s Signature

 

_______________________
Date

 

 


_________________________________________________
Faculty Member who will supervise this internship

______________________
Date

_________________________________________________
Department Faculty Internship Director

 

_______________________
Date

 

 

 

_________________________________________________
Department Chairperson

 

_______________________
Date

 

 

 

_________________________________________________
Academic Program Dean

 

_______________________
Date

 

cc: APSCUF, Records and Registration with all signatures completed (Responsibility of Dean’s Office)

The original application must be returned to the Dean’s Office.  

If an on-campus internship, the Provost’s signature must be included on the bottom of this form.

*Failure to register properly will invalidate this approval. 05.07.2012