Name of Organization__________________________________________________

Address_____________________________________________________________

Telephone/Fax/E-mail/website______________________________________________

Name of Organization Intern Supervisor____________________________________

Internship Job Title_____________________________________________________

Application Deadline:________________ Term(s) applying for: __Fall __ Spring __Summer

Description of Responsibilities (Attach additional information as needed)

Knowledge and Skills Required

Dates of Internship and Hours of Work (Internships require 120 hours of student work for 3 hours academic credit) If this internship includes an honorarium or hourly wage, please indicate the amount.

I have reviewed the description of responsibilities of organization sponsors and agree to participate as described:

Signature___________________________________________Date_________________