Internship placement form

NEW YORK CITY COLLEGE OF TECHNOLOGY
Department of Social Science/Data Analytics Program
300 Jay Street, Brooklyn, New York 11201
saalsberg@citytech.cuny.edu

Please complete this form once the student has been accepted for an internship position. Student will be given permission to register for the appropriate internship class when the form is received.
Please Print or Type

Student’s Name ______________________________ Econ 4201____
Address: ___________________________________________EMPID ________
City: ________State______Zip _________Telephone ( ) ___________
The student has been accepted as an intern.
The student’s schedule will be as follows*:
Day:___________From:__________ To:______
Day:___________From:__________ To:______
Day:___________From:__________ To:______
Day:___________From:__________ To:______
The student is scheduled to start on: _______________Will End on______ (Date)
Name of Organization ________________________________________
Address ___________________________________________________
City__________ State ____Zip ________Telephone ( )____________
Name of student’s immediate supervisor __________________________
Title ____________ Department __________Phone ____
Email of Supervisor_________________________________________________________
briefly describe the duties of the intern:

Supervisor Signature Print Name
____________ __________________
Title:

Telephone:

Internship hours cannot interfere with schedule of classes.

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