Internship Agreement
Ohio State ATI
Student Information
Student Name:
Academic Program:
Home Address:
City:
State:
Home Phone:
Internship Phone:
Cell Phone:
Fax:
Student’s Residential Address while on internship:
City:
State:
OSU e-mail:
Employer Information
Employer (print):
Website:
Employer’s Address:
City:
State:
Zip:
Intern Supervisor (print):
e-mail:
Employer’s Phone:
Cell Phone:
Fax:
May we list information about this internship on the ATI website? Yes No
Position Information
Dates of Employment: to
Position:
Will 50% or more of the work of this internship be conducted outside the state designated in the Employer’s address above? Yes No
If yes, please list the location, state(s):
Position Responsibilities and Duties:
Daily hours of work: a.m. to p.m.
Days per week:
Wages/salary employer is to pay this student: per hour/week/month
Other compensation:
Other information:
Signatures
The undersigned agree to comply with this agreement and provide two weeks notice to all three parties before this agreement is terminated.
The information contained in the Internship Course Syllabus is part of this agreement.
Approved by Employer:
Date:
Approved by Student Intern:
Date:
Approved by Intern Instructor:
Date:
Return this form to the Internship Instructor.
After signing, the instructor will provide copies to the employer, student, and Academic Affairs Office.