Internship Student Information Form & Permit to Register

Please enter all information accurately and completely.

Student Name Student Name * First Last
Student Phone Student Phone * - ### - ### ####
Student Secondary Phone Student Secondary Phone - ### - ### ####
Student Email *
Student Secondary Email
Student Address Student Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Academic School of Program Enrollment *
Academic Major *
Who is your academic advisor?
GPA (must be 2.0 or above) *
Credits Earned *
Expected Graduation Date *
Semester seeking internship *

Semester seeking internship Fall Spring Summer
Year seeking internship *
Location of internship site (Business name, city, state) *
Are you legally eligible to work in the United States *

Are you legally eligible to work in the United States Yes No
Statement of Understanding

Please check the box next to each item to indicate your understanding of the item *

Statement of Understanding

Please check the box next to each item to indicate your understanding of the item 1. I have read the Internship page found on the Internships webpage and agree to comply with the program requirements. 2. I have discussed with and obtained approval from my faculty advisor to determine the number of credit hours to complete my internship. (This form is routed to your advisor for his or her approval)
I have previously enrolled for internship credit. *

I have previously enrolled for internship credit. Yes No
List the total number of previous internship credits, the employer and academic term and year. *
I have completed at least 45 credit hours of college coursework. *

I have completed at least 45 credit hours of college coursework. Yes No
Are you a receiving a Career Scholarship? *

Are you a receiving a Career Scholarship? Yes No
Total number of credit hours completed of college coursework. *
I have completed at least 15 credit hours of coursework at PSC. *

I have completed at least 15 credit hours of coursework at PSC. Yes No
Total number of credit hours completed at PSC. *
How many internship credit hours are you seeking?
(Contact hours include work hours, NOT time spent traveling to/from the worksite and/or any activity outside of the primary work location, i.e., time spent on a bus to/from a game.)

Forty-five contact hours of internship work for each credit hour:
1 credit = 45 contact hours
2 credits = 90 contact hours
3 credits = 135 contact hours
4 credits = 180 contact hours
5 credits = 225 contact hours
6 credits = 270 contact hours
7 credits = 315 contact hours
8 credits = 360 contact hours
9 credits = 405 contact hours
10 credits = 450 contact hours
11 credits = 495 contact hours
12 credits = 540 contact hours *
Name of company where completing internship *
Company Address Company Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Employer's Name Employer's Name * First Last
Employer's Email *
Employer's Phone Employer's Phone * - ### - ### ####
Upload your Internship Learning Objectives form.
You must have all required signatures on this form before submitting. *

Attach Files
I understand that any false information on this or any other internship-related form will be sufficient reason for rejection or termination of my internship, and I will receive a grade of 'F' for the internship. I herewith authorize and request PSC to communicate with my internship site supervisor regarding my performance and herewith hold such persons harmless for giving any and all information within their knowledge or records. It is the responsibility of the student intern to meet the requirements for the Internship Program in a timely manner and within the semester enrolled. Failure to do so may result in termination of the internship or assignment of grade of "F".

Student signature *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date * / MM / DD YYYY