Request for External Academic Intern
PART A: (To be completed by Supervisor/Director requesting External Academic Intern)
Department that is requesting External Academic Intern:
Designated Site-Supervisor of External Academic Intern activities:
Designated Building/Office Location of External Academic Intern:
Name of External Academic Intern:
Phone #
Street Mailing Address:
City: State: Zip:
Home Institution:
Dates of External Academic Internship (authorization may not be effective for more than one year):
Begin: End:
Time periods when External Academic Internship activities will be performed (e.g., 9:00am -3:00 p.m. Mondays
and Wednesdays):
Define the intern’s work duties/responsibilities:
Description of External Academic Internship learning objectives and goals:
Please verify the External Academic Intern is:
Enrolled in a graduate or undergraduate degree program at a regionally-accredited college or university;
In “good academic standing” at their home institution;
Has a minimum CGPA and major/minor GPA of at least 2.0 at their home institution.
Form prepared by: Signature______________________________________________
PART B: (To be approved by the appropriate Vice President)
Please note the following:
The External Academic Intern must not displace Millersville University employees, but works under
the close supervision of existing employees.
Millersville University students should receive preference for on-campus internship opportunities
over students from other institutions.
Provost/Vice President ______________________________________ Date Signed _____________
PART C: (Other Signatures)
Experiential Learning & Career Mgmt ___________________________ Date Signed _____________
Human Resources _______________________________________ Date Signed _____________ _
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