Internship Form B: Description & Employer Contact (PEMC - 3 credits)
Complete this form immediately after accepting a position which you will use for your internship credits. The form is required before you can begin counting hours toward the required 200 hours for RPTS 484. Supervisor name and e-mail are used to request mid-term and final performance evaluations. If you have questions or need further information contact the RPTS Internship Coordinator, Mrs. Susan Scott, at firstname.lastname@example.org.
What is your major? (If RPTS or CDEV, use the appropriate 6-credit internship form.)*COMMHORTProfessional Event Management Certificate (PEMC): Students from any major who have been accepted into the PEMC program may use 3 credits (200 hours of work plus written assignments) of an event management internship toward Certificate requirements in place of another approved 3-credit course. Students minoring in RPTS may use a 3-credit internship as an elective, but not in place of required courses.I am working toward an minor in RPTS and wish to use a 3-credit internship as an electiveI have been accepted into the PEMC programI have applied to PEMC and am awaiting acceptanceI plan to apply to the PEMC programYour Name*
Cell Phone*Employer/Host Organization*Name of company, agency or organizationDepartment or Division (if specified)Starting Date of Internship (date format mm/dd/yyyy)*
Ending Date of Internship
How many hours per week do you expect to work at your internship site during the months you have listed above?Name of Your Supervisor
Prefix = Mr., Ms., Dr., etc.; if you do not yet have supervisor information, e-mail it to Mrs. Scott ASAP.Supervisor's Job TitleSupervisor's E-mail AddressSupervisor's Phone NumberOrganization/Company Office Address*
Address Line 2
State / Province / Region
ZIP / Postal Code
AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe
Job Description*Type a list or brief overview of the position's main duties based on the information you have received thus far.During which semester do you intend to register for RPTS 484?*Spring 2015Summer 2015Fall 2015Spring 2016Summer 2016Fall 2016Spring 2017Summer 2018Your Permanent Address*
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
Emergency Contact Name*
Parent/Spouse/Significant OtherEmergency Contact Phone Number*What is your overall GPA/GPR?*
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