PLEASE PRINT THE INFORMATION REQUESTED BELOW:

This form certifies that I,                                            (student intern), have informed my internship immediate supervisor,                                           , that I will be working another job while completing my internship.

My other job information: Place of employment:  Position:  General schedule of work hours: General responsibilities:

signed:                                                                                                                            student intern                                                           date

signed:                                                                                                                           intern supervisor                                                    date

Submit this form with the first weekly log, or the first log after which you secure other employment.
** should a conflict of interest arise between the internship employer and the second employer,
students should cease work at the second job.
*** if a student does not infom his/her internship supervisor of a secondary job and conflict later arises
as a result, the student will not be supported by this internship instructor and the employer's final
evaluation will still be taken seriously.