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
AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe
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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