College of Staten Island
 The City University of New York
 
  

Career and Scholarship Center
 Internship Placement Form

If you have been successful in securing an internship, please complete this form and submit it to the Career and Scholarship Center.  Thank you.

Student Information
Name:    
SS# (last 4 digits):
Street Address:
City:    State:    
Zip Code:
Home Phone: ( ) -
Cell Phone: ( ) -
Organization Information
Organization Name:
Department:   
Location: City State:
Supervisor’s Name:
Supervisor’s Title:
 
Type of Internship
(Please Check All That Apply)
Paid       Credit       Volunteer
Internship Title:
Start Date (mm/dd/yyyy):      End Date (mm/dd/yyyy):
 
How I found the Internship?
(Please Check All That Apply)
OptimalResume       Internships.com       Internet       Family/Friend
Faculty       Other (please state where)