Student Information
Full Name:
Street Address:
City: State: Zip Code:
Home Phone: Cell Phone:
School E-mail Address:
School Name:
Major: G.P.A.:
Program Level: High School Junior/Community College Undergraduate College/University Graduate/Law School
Expected Completion Date/Degree:
UNITED STATES COPYRIGHT OFFICE
5
Internship Written Permission Request Form
REVISED
:
11 ⁄ 2017
ADMINISTRATIVE
SERVICES OFFICE
Period of Internship
Start Date: Ending Date:
Schedule:
Reason: Academic Credit Student Service Learning (SSL) Hours Training/Experience
(If academic credit is selected, attach a copy of the program requirements/agreement. SSL forms must be submitted prior to departure.)
Student Armation and Signature
By signing this, I arm that the facts set forth in this document are true and complete. I understand that having been accepted as an
intern with the U.S. Copyright Oce, any false statements, omissions, or other misrepresentations made by me on this document may
result in my immediate dismissal.
Student Signature: Date:
If under 18 years of age, a parent/guardian’s signature is required.
Parent/Guardian’s Signature: Date:
Parent/Guardian’s Name:
Phone: E-mail Address:
School Representative Armation and Signature
By signing this, I arm that meets the eligibility requirements of being
a student (enrolled not less than half time and if between school years, not more than ve months) in good standing with the school or
college/university designated above. Permission to intern with the U.S. Copyright Oce under a voluntary services agreement is granted.
Signature: Date:
Name:
Position: School Name:
Phone: E-mail Address:
Return on start date to: U.S. Copyright Oce phone: (202) 707-8370
Administrative Services Oce fax: (202) 252-3668
101 Independence Avenue, SE, LM 458 email: copyrightinternships@loc.gov
Washington, DC 20540 website: copyright.gov
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
