Registration in an Internship for Course Credit
Name: _________________________________________ Student ID#
Date: ________________ Course to be taken during term: ____________________ Year:
Course Number: ___________ Course Title: _______________________________ _ Credit Hours:
Instructor of the Course:
Total hours registered after adding course: _______________________________________________________
Internship Company/Organization Name:
Supervisor’s Name:
Supervisor’s Email: Phone:
A copy of the Internship Agreement must accompany this form.
Please obtain signatures in the following order.
Student Signature: Date:
Advisor Signature: Date:
Instructor Signature: Date:
Department Chair of Instructor Signature: Date:
Dean Signature: Date:
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