APPLICATION FOR UNDERGRADUATE FIELD EXPERIENCE College of Management University of Wisconsin-Stout I. PERSONAL INFORMATION Name Student ID# Address while on field experience City State Zip Home Address City State Zip Phone # on Field Experience Home Phone # Major Email Address Minor/Concentration II. EMPLOYER INFORMATION Supervisor’s Name Supervisor’s Title Company Name Address City Phone Your job title Dates of Employment: to State Zip Planned # of hours per week Brief job description (duties and responsibilities) Have you previously worked for this employer? If yes, in what capacity? Yes No III. LEARNING OBJECTIVES YOU HOPE TO ACHIEVE The purpose of this section is to encourage you to stop and reflect what you want to achieve from this experimental learning course prior to undertaking it. You should realize that is a possibility that not all of the objectives stated will be achieved, and others objectives may develop. 1. List the major and minor learning objectives you plan to obtain from this field experience. Please number and describe separately. Be specific to the skills, knowledge, attitude, etc. you hope to develop or improve from this experience either directly or indirectly. 2. Describe how you hope to achieve the above objectives. D. APPROVAL FORM 1. I accept the responsibility of coordinating this student's work experience. ______________________________________________________________________ Signature of Experience Coordinator Date 2. I confirm that this Field Experience relates to our department. ______________________________________________________________________ Signature of Department Chair Date 3. I authorize the use of these credits in filling the requirements of the _________________________________ (Degree major or minor) as _____________________credit. (required or elective) Signature of Program Director Enrolled ______________Fr Date So Jr Sr ___Only course taken ___ Add card _______________________________ Course number (2 credits) __________________________ Semester Enrolled OR if taken 1 credit in different semesters _______________________________ Course number (1 credit) __________________________ Semester Enrolled _______________________________ Course number (1credit) __________________________ Semester Enrolled Approval letter received from employer ______________________________ Periodic Learning Reports (2) ____________ Evaluation received from supervisor___________ _____________ Final Report___________ Return application form (with the required signatures) to: Sue Jasperson 280 TW, UW-Stout, Menomonie, WI 54751 ph: 715-232-2696, fax: 715-232-1274 e-mail: jaspersons@uwstout.edu