Internship Data Sheet _______ Thanks for completing all the information below for entry into the Internship Inventory. Please return this information to Christina Rosen, rosencm@appstate.edu Student Banner ID: First Name: Middle Name/Initial: Last Name: ASU Email: Faculty Supervisor Address: First Name: City: Last Name: State: Zip Code: Phone: Internship Site Supervisor GPA: Information First Name: Last Name: Emergency Contact Title: (Who may we contact in case of Phone Number: emergency) Email: Name: Fax: Relationship: Address: Phone Number: City: State: Zip Code: Agency Details Agency Name: Country: Phone: Address: Course Information City: Internship Start Date: State: Internship End Date: Zip Code: Course Number: Course Title: Physical location of internship Credit Hours: Same as internship details above Average Hours per week: If different than above Domestic or international (please Compensation circle one) Unpaid Address: Paid: City: Pay Rate: State: Average Hours per Week: Zip Code: Country:
Internship Data Sheet _______ Thanks for completing all the information below for entry into the Internship Inventory. Please return this information to Christina Rosen, rosencm@appstate.edu Student Banner ID: First Name: Middle Name/Initial: Last Name: ASU Email: Address: City: State: Zip Code: Phone: GPA: Emergency Contact (Who may we contact in case of emergency) Name: Relationship: Phone Number: Agency Details Agency Name: Phone: Address: City: State: Zip Code: Physical location of internship Same as internship details above If different than above Domestic or international (please circle one) Address: City: State: Zip Code: Country: Faculty Supervisor First Name: Last Name: Internship Site Supervisor Information First Name: Last Name: Title: Phone Number: Email: Fax: Address: City: State: Zip Code: Country: Course Information Internship Start Date: Internship End Date: Course Number: Course Title: Credit Hours: Average Hours per week: Compensation Unpaid Paid: Pay Rate: Average Hours per Week: