INTERNSHIP/PRACTICUM PROGRAM

Name:       ________________________________   Home Phone:    _____________________________

Address:    ________________________________   Work Phone:     _____________________________

                 ________________________________

Major:       ________________________________

Class

Standing:    ________________________________

GPA:         _____________________

Employment Interests:

Previous Work Experience:

Special Skills: (e.g., typing, data processing, photography, etc.)

When do you wish to begin an internship program?

For 3 hours _______ or for 6 hours ________?