Internship Connect Program
Wesley College & Central Delaware Chamber of Commerce
For 2012-2013 Academic Year
PERSONAL INFORMATION
Name: _______________________________________________________
Last
First
Date: ____________
Middle Initial
Home Address: ________________________________________
Street
________________________________________
City
State
Zip
Phone: (_____)______________________
Email Address: __________________________________
Major: _____________________________
Student ID #: ________________________
Check all that apply: Transfer: ___ Male: ____
Female: ___
Fresh: ____ Soph: ____
Jr: ____
Resident:___ Commuter:____
Sr: ____
Total Semesters Completed at Wesley College: ________
Expected Graduation Date: _________________
(semester/year)
Major:_____________________________________ Minor: ________________________________________
Last Semester’s Wesley GPA: _______________
Overall Cumulative Wesley GPA: ___________________
YOU MUST HAVE A MINIMUM 2.50 CUMULATIVE GPA AT THE END OF THE SPRING 2012 SEMESTER
TO BE CONSIDERED FOR THE INTERNSHIP CONNECT PROGRAM
INTERNSHIP INFORMATION
Internship Company Name: ________________________________________________
Internship Company Address: _______________________________________________
Street
_______________________________________________
City
State
Zip
Company Industry: _________________________________ Expected Internship Hours: ________________
Name of Contact Person: ____________________________ Title of Contact Person:____________________
Business Email: ___________________________________ Business Phone #: (_____)_________________
Will this internship be used for academic credit? If so, please provide the class code and instructor name.
Yes
No
Class Code: ____________________
Instructor Name: ________________________ _____
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CERTIFICATION OF INFORMATION PROVIDED
I understand that my signature below:
1. Certifies that the information which I am providing within this application is, to the best of my knowledge,
accurate and complete;
2. Certifies that I am not currently on any type of judicial probation and that I understand that my judicial
record will be reviewed and considered prior to my internship placement;
3. Indicates that I voluntarily give the Department of Academic Support permission to verify the information
that I have provided.
________________________________________________
Signature
______________________
Date
ADDITIONAL SIGNATURES (obtain in the order shown)
________________________________________________
Coordinator of Career Services Signature
______________________
Date
________________________________________________
Wesley Internship Mentor/Supervisor Signature
______________________
Date
________________________________________________
Company Contact Person Signature
______________________
Date
APPLICATIONS ARE DUE TO THE OFFICE OF CAREER SERVICES
INTERNSHIP PRECONDITION CHECKLIST:
CONDITIONS MUST BE MET BEFORE STUDENT CAN PARTICIPATE IN PROGRAM
_____
_____
_____
_____
_____
_____
_____
_____
_____
1) Student is classified as at least a sophomore and full time as of the end of Spring 2012
2) Student has at least a 2.5 cumulative GPA as of the end of Spring 2012
3) Student is in a good judicial standing
4) Student met with Coordinator of Career Services to review their resume and interview skills
5) Student selected an internship to apply to
6) Student has attached a copy of the internship description & contact information for the company
7) Student meets the qualifications of the employer
8) Student will have no more than nine credit hours of internship at graduation (if applicable)
9) Student meets department criteria for GPA and required curriculum (if applicable)
INTERNAL USE ONLY:
Date Application Received: ______________________________
Date of Student Meeting: ________________________________
Date Application Forwarded to Academic Department: _____________________
Application Forwarded to: ________________________________
Date of Follow-up: ________________________
Result: _________________________________________________________________________________
_______________________________________________________________________________________
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