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Practicum Online Application
for the Pre-Professional Health Program
Today's Date:
Semester/Year when you are requesting practicum (ex. Spring/2000):
What practica field are you interested in? (ex. HLSC ... - Med, Dental, etc.):
Name:
Social Security Number:
Year: Frosh
Soph
Jr
Sr
Email Address:
Home Address:
City:
State:
Zip:
Phone:
Campus Address:
Campus ext:
Do you have a car: YES
NO
ACADEMIC INFORMATION:
Academic Major:
Academic Minor:
GPA (in Major):
GPA (overall):
At time of application, (not including current semester),
number of credit hours completed
AT Benedictine University
:
CAREER INFORMATION
(Please Be Specific)
What are your career goals, if any?
In what career area(s) are your interests?
WORK EXPERIENCE:
(Please list the following information for
EACH EMPLOYER
):
Name and Address of Employer
Job Description
Number of hours/week
Dates Employed (from/to)
PLEASE NOTE:
This form is being submitted to Ms. Alice Sima at: asima@ben.edu. Submission of this form authorizes the Director of Pre-Professional Health Programs and any appropriate faculty advisors to use this Practicum Application Form on your behalf, and grants permission for the information provided in this form to be made available to prospective cooperating organizations if requested.
IMPORTANT:
You must sign up for an interview time with Ms. Sima (sign up sheet is on her door-Birck 322) beginning on April 2nd. APPLICATIONS MUST BE SUBMITTED BEFORE YOU MEET WITH MS. SIMA
Please print a copy of your completed form for your records
Update January 21, 2007
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