Student Intern Placement Information Summary Form

Required fields are marked with an asterisk (*).

Student

Student's Name

W#

Student's Email Address

Course

Quarter / Year of Registration of PLSC 444

Number of Credits

Agency

Agency

Office Address

Supervisor's Name

Supervisor's Title

Supervisor's Address

Supervisor's Email Address

Supervisor's Phone

Internship

Intern's Work Phone

Duration (no. of weeks) of the internship

Working hours of the internship

Description of expected assignments/duties