Internship Agreement, Southeast Missouri State University


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Internship / Practicum Agreement

Student’s Name:
SE ID (S0#######):
Major:
Total Hours Completed
Total Hours Completed in SC Courses

Campus Address
Campus Phone

Cooperating Agency Information

Company Name
Company Address
Supervisor
Title
Phone Number
Internship Title for Permanent Records
Starting Date of Internship
Closing Date of Internship
Number of Weeks of Internship

List of Internship Work Tasks:

Additional Requirements to be fulfilled before credit is granted for internship/practicum:

Weekly Time Log to be submitted via email at the end of each weekly period for the total of 180 hours worth of work.
Two on-job work samples representing the internship (can be in draft form).
Supervisor’s Internship Performance Review Form.
Self & Program Evaluation Form.

All materials and information submitted for your Internship/Practicum become property of the Department of Communication Studies to be maintained in the main department office. These items cannot be returned.

Student’s Signature
____________________________________________ Date _________________________

Company Representative’s Signature
____________________________________________ Date _________________________

Internship/Practicum Coordinator's Signature
____________________________________________ Date _________________________

Department Chair’s Signature
____________________________________________ Date _________________________