CLAYTON   STATE   UNIVERSITY

OFFICE OF CAREER SERVICES

Technology Bldg. 113    (678) 466-5400

 Student Information for Internship

(Please print!)

Name                                                                                                                                                 

Address                                                                                                                                              

                        (house or apartment number, street)  

                        (city     state    zip)

 Phone (1)                                                                                 (2)                                                       

  Email: csu ______________@mail.claytonstate.net            Overall GPA                                        

 Major or Concentration                                                                                                                      

 Expected Graduation Date                                                                                                                

  Semester to Participate in Internship                                                                                                  

AUTHORIZATION TO RELEASE STUDENT INFORMATION  

I hereby authorize the Office of Career Services and/or my faculty coordinator at Clayton State University to release, on my behalf, to potential internship sites my GPA, resume, or other such information contained in my educational records as is necessary to aid the organizations in assessing my potential for participation in an internship. I further authorize the Office of Career Services to communicate with an internship site regarding my work performance during the semester(s) of participation.

 I understand that this information will be disclosed to those persons at the internship site who have been determined by that organization to have a need to know.  I understand that this information is being released pursuant to the Family Educational Rights and Privacy Act of 1974 and will not be released to other parties without my consent.

        signature                                                                                                date