Student Intern Placement Information Summary Form

Student's Name:

WWU ID:

Student's E-Mail Address:

Quarter / Year of Registration of PLSC444:

Number of Credits:

Agency:

Office Address:

Supervisor's Name:

Supervisor's Title:

Supervisor's Address:

Supervisor's E-Mail Address:

Supervisor's Phone:

Intern's Work Phone:

Duration (no. of weeks) of the internship:

Working hours of the internship:

Description of expected assignments/duties: