Southeast Missouri State University

Student’s Name:
SE ID (SO#######):
Local Address
Local Phone
Expected Date
of Graduation
Semester you desire
an internship/practicum
Type of internship you desire
Preference of internship location
Hours completed
toward a degree
Communication Studies courses and relevant UI courses (301, 345, 423, 425, 504)

Course #     Title     Grade      Semester/Year Taken
Pertinent Work Experience:
Position   Company Name/Address    Dates      Supervisor
Special Skills (computer, FCC License, writing ability, art ability, etc.):
Career Goal (list):
 Student Signature:_____________________________________Date:________