*ALL INFORMATION IS REQUIRED*

Your Name: ID Number:

Campus Phone Number: Permanent Phone Number:

E-mail Address:

School Mailing Address:

Permanent Mailing Address:

Who is your advisor:

# of Credits you want for the internship:

Are you certified?
Yes No

Which semester are you looking to do the internship in?
Spring Summer Fall

Which sequence are you enrolled in?
Advertising Broadcasting Communication
Communication Studies Journalism Public Relations

If you are in Public Relations,
check the following courses you have taken or will have taken prior to doing the internship:
PR 312 PR 313 JOUR 305 COM 295

If you have found an internship already, please fill out the following:

Company Name:

Company Phone Number:

Company E-mail Address:

Company Mailing Address:

Supervisor's Name:

Supervisor's Phone Number:

Fax Number:

I agree that I will perform in a professional manner and will follow the instructions and policies of the organization where I will be interning. I understand that I will submit a written report describing my activities and evaluating my experience at the conclusion of my internship. This must be done in a satisfactory manner before credit will be granted. I understand that I must enroll for credit with WSU that corresponds with the number of hours I work, and if I drop or fail to pay tuition fees, I will be dismissed from the internship program and the on-site supervisor will be notified that I am no longer with WSU. I realize that my GPA (in Communication Courses) must be at least 2.7 to qualify for an internship.

If you certify that the above stated is accurate and true to the best of your knowledge, please type your name and date on the form and click the SUBMIT button.

Signature

Date

Submit the information OR
if the form will not submit, print it out and return it to the Internship Coordinator in Murrow East 227 .