internship application form usth 2017
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Vietnam Academy of Science and Technology
University of Science and Technology of Hanoi
INTERNSHIP PROGRAM APPLICATION FORM
STUDENT’S INFORMATION
(DD/MM/YYYY)
Date of Birth
First name
Last name
Origin of birth
Present nationality
Other nationalities (if any)
Passport Number
Place of issue
Date of Expiry
Local Mailing Address
(
)
-
Local Telephone Number
City
(
)
State
-
(
Work Telephone Number
)
Zip
-
Cell Phone Number
__________________________________
___________________________________
E-mail Address
Major
Minor
Class Standing
Expected Graduation Date
Cumulative GPA
Emergency Contact Name
Relationship
(
)
Telephone Number
__________________
Semester & Year
HOME INSTITUTION INFORMATION
University
Department
College/School
Internship Supervisor
Title
Department Mailing Address
City
(
E-mail Address
State
)
Telephone
-
Zip
2
2
Academic Advisor (if different from above)
Title
(
E-mail Address
)
-
Telephone
USTH’S SPONSORING DEPARTMENT INFORMATION
Sponsoring Organization: Hanoi University of Science and Technology of Hanoi
Division/Department:
Head of Division/Department:
Have you contacted internship supervisor of USTH?
Yes
Internship Supervisor:
No
Supervisor’s Title:
Location of Job:
Summary of Job:
STUDENT’S INTERNSHIP PLAN
Start Date:
End Date:
Month
Day
Year
Work Schedule:
Month
Day
Year
Hours Per Week Expected:
Supervisor/Student Contact Hours:
Financial plan for internship
Self-support
Home institution/supervisor
Other sources (please specify):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Type of internship program:
Paid
VND
Per ( Hr/ Wk/ Mo)
Credit
Number of credit
Unpaid
Non-credit
Request support from USTH’s Division/ Department:
Finding room & board
Stipend
Scholarship
VISA
Others (please specify)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
On-site Activities/Responsibilities: _____________________________________________________________________
3
3
Physical Demands/Work Environment:
Equipment/Machinery to be used:
Other:
STUDENT’S INTERNSHIP OBJECTIVES AND CONTENTS
Time
Content
Signature of student and home institution supervisor:
Student
Date
Supervisor
Date
Academic Advisor (if any)
Date
Approval of sponsoring department and supervisor:
Sponsoring supervisor
Date
4
4
Head of division/ department
Date
International Officer
Date
