PSIP-Albany Internship Application
Name ______________________________
Banner ID ____________________
Number of Credits __________
Date of Participation Spring __________ Summer __________
Fall __________ Winter __________
Class ____________________
Anticipated Graduation Date __________
Major/Minor ______________________________
Overall GPA __________ Total Credits Earned __________
STUDENT CONTACT INFO
Phone ____________________
Email ______________________________
Permanent Address
________________________________________
________________________________________
________________________________________
EMERGENCY CONTACT INFO
Name ______________________________
Phone ____________________
Permanent Address
________________________________________
________________________________________
________________________________________
Please supply one faculty reference who can speak to your abilities.
Name ______________________________ Title ______________________________
Phone ____________________ Email ______________________________
Please return this completed application, your learning agreement, a one to two page biographical
statement, a current transcript, and one completed faculty reference form to the Career Services office
in Rakov 101. If you have any further questions, please contact Rob DiCarlo.
Career Services
Attn: Rob DiCarlo
Rakov 101
350 New Campus Drive
Brockport, NY 14420
585 395 2159 (phone)
585 395 2708 (fax)
FOR OFFICE USE ONLY
Learning Agreement Biographical Statement
Reference Letter Transcripts Résumé
Application Approved Disapproved Date ____________________
Agency Placement/Supervisor __________________________________________________