Student Internship Form

Student Information

Name Enter your first and last name

Date

Year / Month / Day

Your Penn State E-Mail Address

Alternet Email Address

Local Telephone Number Enter your local telephone number where you may be contacted.

Student ID Number Enter your 9-digit student ID number. This is NOT your Social Security Number (SSN).

Major

Semester Standing

Internship Site Information

Organization Sponsoring the Internship

Internship Information

Semester of Internship

Number of LA 495 Credits

Internship Begins Enter the date that the internship is to begin.

Year / Month / Day

Internship Midpoint

Year / Month / Day

Internship Endpoint

Year / Month / Day

Number of Weeks

Number of Hours/Week

Total Number of Hours

Internship Supervisor Information

Supervisor Name

Supervisor Title

Telephone (residence)

Office Address

City

State

Zip Code

Office Telephone Number

Fax Number

Hourly Pay Rate If internship is unpaid, please enter a 0

How did you find your internship?

Department of Sociology and Criminology