A. Student Information: (to be completed by student)

Name:
Address:
City:   State:   Zip:
Telephone:  Email: 
Student ID: 
Chemistry Option:  Advanced BiochemistryAdvanced ChemistryBiochemistryBusinessChemistry EducationChemical EngineeringEnvironmental ChemistryForensic ScienceMaterials SciencePreMed
Class Standing:  SophmoreJuniorSeniorPost Bac

B. Intern Employer Information:  (to be completed by student and intern supervisor)

Organization/Agency:   
Intern Supervisor's Name: 
Title: 
Address: 
City:    State:    Zip:
Phone:    Email:   
Web Address: 

C.  Internship Information:  (to be completed by student and the agency supervisor)

Student's Job Title: 
Intern Compensation:
$ per hour  week  month stipend
Duration of Internship: 
Location of Internship: 

Description of Internship assignments: (please enter a return at the end of each line)


Start Date:  Month:  Choose Month January February March April May June July August September October November December      Day:     Year:  
End Date:    Month:  Choose Month January February March April May June July August September October November December      Day:     Year:  

D. University Information:  (to be completed by student and faculty advisor)

Chemistry Faculty Advisor for Internship: 
Office Address:    Telephone:    Email:  

Is this internship for credit? Yes   No
If for credit,  how many credits?
The student must register for this number of CH 410 credits before beginning the internship.  Registration must be done in person at the main chemistry office, Gilbert Hall 153.

E. Student Learning Objectives: (to be completed by student and shared with agency supervisor and faculty advisor)

List what information and experiences you want to gain by the end of the term.  Examples:  I want to better understand what jobs chemists perform in industry.   I want to learn what "Quality Control" chemists do for industry.  I want to learn about techniques used for large scale synthesis.  I want to learn about chemical production schemes. etc.

1. 
2. 
3. 

Responsibilities include:

Student Responsibilities to Employer & Faculty (e.g., supplemental reading, keeping a scientific notebook, preparing reports, attending staff meetings and training sessions, etc.  Give projected due dates where possible.)

(please hit return at the end of each line)

Employer Responsibilities to Student &  Faculty Advisor (e.g., opportunities, level of supervision, scientific duties expected of intern, support for work and intern,  evaluation of intern's work , etc.)

(please hit return at the end of each line)

F. Signatures

Student Intern:          ____________________________         Date: ________________

Intern Supervisor:    ____________________________           Date: ________________

Faculty Advisor:      ____________________________            Date: ________________