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 Armation and Signature
By signing this, I arm 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 Oce, 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/guardians signature is required.
Parent/Guardians Signature: Date:
Parent/Guardians Name:
Phone: E-mail Address:
School Representative Armation and Signature
By signing this, I arm 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 Oce 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 Oce phone: (202) 707-8370
Administrative Services Oce fax: (202) 252-3668
101 Independence Avenue, SE, LM 458 email: copyrightinternships@loc.gov
Washington, DC 20540 website: copyright.gov
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