Name of Internship:

Full Name of Student

First:

Middle:

Last:

Social Security Number (needed to verify GPA):

Preferred Name:

Class Year:

Major:

Minor (if applicable):

Faculty Advisor:

Preferred Email:

Daytime telephone:

Housing

We are trying to maximize available housing for the competitive internships. Do you have alternative housing in the location where you are applying for an internship? ___Yes ___No. If yes, please explain:

Release of Information

I hereby grant permission to the Career Center staff and individuals involved in the internship selection process to contact campus officials to verify that I am in good standing academically, financially, that my GPA is accurate as reported, and that I am clear of disciplinary action with respect to the Honor Court and Student Conduct Council. I also grant permission for consultation with my faculty advisors, professors, and administrators with respect to the selection process for the Competitive Internship Awards Program.

_________________________________________________       ___________________________________

Student signature                                                                    Date:

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