DCBA Internship Approval Form

Student Name: *

Student ID Number: *

Student Phone Number: *

Student E-Mail: *

Semester(s) internship will take place in: *

Fall

Spring

Summer

Select all that apply

Start Date at Organization: *

Completion date at Organization: *

Academic Credit Type : *

Credit hours requested: *

Estimated hours of work per week: *

Name of Supervisor: *

Supervisor’s Position/Title: *

Organization Name: *

Organization Address: *

Organization City: *

Organization State: *

Organization Zip Code: *

Supervisor’s Telephone: *

Supervisor’s Fax Number:

Supervisor’s Email: *

List any family working at this organization:

Pay Rate (if applicable): * $

Job Description: *

Describe, in detail, your role, duties, and responsibilities while interning.

Student Learning Objectives and Goals: *

Please list a MINIMUM of three (3) goals to be learned through this experience. These goals MUST explain how they relate to your major AND how they will improve your skills as a professional.

Student Approval: *

I agree to participate in the internship experience as outlined above.

By submitting this document, I agree to the above terms and understand that this document will be forwarded, via the provided email, to my supervisor for approval. I have been provided an “Internship Grading Rubric” and understand the requirements outlined to receive academic credit for this experience. I also understand that since this experience is for academic credit, I must adhere to all guidelines outlined in the Student Code of Conduct and the DCBA Student Honor Code while interacting with this organization. I understand and agree to my responsibilities relating to this internship experience.

James F. Dicke College of Business AdministrationOffice of Experiential Learning

James F. Dicke College of Business Administration
Office of Experiential Learning