If you are interested in applying for 693 credit for field/internship experience, please answer the following questions and give it to your prospective 693 faculty supervisor before you start the experience. The internship must be approved in order for you to receive course credit.

Name________________________________________________________________________

Address______________________________________________________________________

Email address_________________________________________________________________

Telephone number______________________________________________________________

Social Security number__________________________________________________________

Name, address, and telephone number of internship location______________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Will you be paid for this internship activity? _____yes _____no

Description of activities in which you will participate:

Description of training component (content, frequency, length of time devoted to training):

Approximate total hours to be spent on this activity during the quarter________________

Starting date________________