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					                                                                                 Date Registered (for the Registrar to initial): _________________________

                                  Internship Application and Registration Form
                               Internship Program – Career Services – DeSales University
                 Fax: (610) 282-3734   Phone: (610) 282-1100 Ext: 1738

Student Name: _____________________________________                               ID#: _________________________________

Email Address: ____________________________________                               Phone Number: _____________________________

Major: ________________________________                                 Academic standing: ____SO ____JR ____SR ____ACCESS

Number of Credits Sought: ________ (Internships are normally 3 credits 120-150 hours)

Internship Course Department and Number: _________________________ (see college catalog for Dept. Course #)

(OFFICE USE ONLY): Cum. GPA : ________ Approval Initials ________

Name of Employer/Company/Location Sponsoring Internship: _______________________________________________

Is your internship: _____unpaid            ______paid $ ______ per hour

*Check the Semester you will be interning and state the appropriate dates (Please Note: During the summer, DAY
students are charged at ACCESS rate- charged per credit.):
                                               Fall                    Spring                 Summer                  Start Date             End Date
        Academic year
                                             semester                 semester                semester

As a requirement to participate in this internship, I certify that I am enrolled in the Student Accident and Sickness
Insurance Plan or have coverage under my family or personal accident insurance plan. Furthermore, I agree to
comply with the Internship Program’s requirements: Resume/ Copy of Offer Letter/Learning Contract/Student and
Employer Evaluations/Final Report/Log of Hours.

Student Signature: ____________________________________________                                    Date: ___________________

**It is important that you obtain the signatures in the order which they are listed below:

_________________________________                       __________
Director of Career Services Signature                   Date
(The Director of Career Services confirms that the student has an approved internship site and initiated enrollment into the Internship Program by
submitting an application, offer letter/email, and resume.)

_________________________________                       __________            _________________________________                        ___________
Faculty Supervisor Signature                            Date                  ACCESS Advisor Signature (if applicable)                 Date
(The faculty supervisor confirms that the student has an approved internship site and initiated enrollment into the Internship Program. Also, the faculty
supervisor MUST schedule at least two meetings with the student during the semester. In cases where meetings are not possible, regular contact by
phone or email must be maintained.)

_________________________________                       __________
Registrar Signature                                     Date

Additional Signatures are required for the following: 1) Applicant’s GPA is not higher than 2.5 2) Applicant is a
sophomore 3) Applicant is requesting a 6 credit internship 4) Internship will put applicant at a course overload

_________________________________                       ___________________
                                                                                                    **OFFICE USE ONLY: Check reason for signatures
Signature of Dept. Chair or Division Head               Date
                                                                                                        GPA < 2.5
                                                                                                        Sophomore standing
_________________________________                       ____________________                            6 credit internship request
Dean of Undergraduate Ed.                               Date                                            1 course overload

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