PRELIMINARY APPLICATION FOR INTERNSHIP
CA/CS/NW 269 Internship Course & Program

Semester____________ Year ____________ U.S. Citizen � If Not U.S. Citizen, Provide Current Visa Status___________________

CA 269 Computer Applications Internship �
CS 269 Computer Science and Technologies Internship �
NW 269 Network & Wireless Internship  �

 

Name ________________________________________________

 

________________________________
First MI Last Student Identification Number

 

Mailing Address _______________________________________

 

Work Phone ( ) ________________

Apt. # Home Phone ( ) ________________

 

City __________________ State _______________ Zip _______

 

E-mail ___________________________

Education (Degrees Earned & University/College) :
Major : GPA:

Computer Applications and/or Computer Science Department Courses Taken:

(Note - Minimum 12 credit hours of completed courses required.)

Course & Section # Course Title Credit Hours Grade*

*Use midterm grades if semester is still in progress.

Network and Wireless Department Courses Taken:

(Note - Minimum 12 credit hours of completed courses required.)
Course & Section # Course Title Credit Hours Grade*

*Use midterm grades if semester is still in progress.

Mathematics Courses Taken:

Course & Section # Course Title Credit Hours Grade*

*Use midterm grades if semester is still in progress.

English Courses Taken:

Course & Section # Course Title Credit Hours Grade*

*Use midterm grades if semester is still in progress.

Desired number of work hours per week (check as many as apply):

5 hours ____________ 10 hours ____________ 15 hours ____________ 20 hours ____________

Other degrees/certificates/skills:

CERTIFICATION and RELEASE

I certify that the information contained in this application is accurate and complete. I understand this information will be released by Montgomery College to prospective employers to assist me in seeking qualified, college-credit internships. I understand that all hiring and supervisory decisions are the responsibility of the employer, not Montgomery College. I hereby authorize Montgomery College and its employees and representatives to release this application, the information it contains, and any supplemental information from my files and records, to prospective employers upon request.

Student Signature ________________________________________ Date _________________________

(For more information contact Prof.. Raymond Kimball at (301) 208-3025. 03/06