TARLETON STATE UNIVERSITY

GEOSCIENCES INTERNSHIP PROGRAM

Name _________________________________________________ Date ________________

Student Identification or Social Security No.________________________________________

Local Address ____________________________________________ Phone _____________

___________________________________________________________________________

Permanent Address ___________________________________________________________

___________________________________________________________________________

Degree Sought: _______________________ Expected Completion Date: ________________

Units Completed (total) ________________________

Units Completed in Concentration Area ___________

Grade Point Average __________________________

Faculty Advisor ___________________________________________Phone ______________

Statement as to why you want to be involved in this program and what you expect to gain from it. Be specific.

Supervisor’s Name _______________________________________ Phone ______________

Sponsoring Organization ___________________________________Phone ______________

Address ____________________________________________________________________

___________________________________________________________________________

Dates to be involved in program. From ___________________ to _____________________