Change of Internship Provider Submission Form

Change of Provider Submission Form

This form is only to be used if you plan on changing your current internship provider due to unforseen circumstances. Important : You cannot request for a FT internship from PT or reduce from FT to PT. All Change of Internship Provider Requests must be dated at least 1 week out from the date of request and must have prior approval before ending the current internship.

(Do not begin an internship with the new provider until this request is approved. Students attending ITU on an F-1 visa must also wait until an updated I-20 is issued.)

Student Information

Full Name *

First Name Middle Name Last Name

Student ID # *

E-mail Address *

Degree *

Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Internship Information

Hours *

Part Time (under 20 hrs/week) Full Time (21-40 hrs/week)

Internship Provider Name *

Internship Title *

EIN (9 digit tax ID number) or E-verify (4-7 digit number) *

Internship Provider Website *

Is this position paid or unpaid? *

Paid Unpaid

Address of Internship Provider's Headquarters *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Supervisor Full Name *

First Name Last Name

Supervisor Phone Number *

Area Code Phone Number

Supervisor Email Address *

Please list the same email address used in the Offer Letter.

Human Resources Manager Name *

First Name Last Name

Human Resources Manager Email *

Human Resources Manager Phone Number *

Area Code Phone Number

Were you terminated from your current Internship?

Yes No

Why you were terminated from your current provider *

If terminated, we may contact your previous supervisor

Why are you Changing your Provider? *

*** Students at ITU are limited to one internship provider at a time and one change of internship provider per trimester. By signing this form, the student confirms that all activity with the former internship provider has ended as of the date below. Students attending ITU on an F-1 student visa will violate ITU policy and visa regulations if activity with the previous internship provider continues. ***

Additional Information

Are you an international student? *

Yes No

Visa Type: *

F-1 H1b H4 (Authorized EAD)

SEVIS ID Number *

CPT I-20 Shipping Options: *

In-person pickup Standard U.S. mail shipping USPS Express Mail (additional fees will apply)

Mailing Address: (if different from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

If you are an H1B student, we recommend that you consult with your lawyer prior to any Change of Internship Provider.

Phone Number *

Area Code Phone Number

Required Forms and Acknowledgements

Check to make sure you filled out and completed all student sections of the Internship Request Form.

Step 1: Student Section - make sure all parts are filled in correctly and marked

Important:

Save your file as follow: Continuing Internship Provider Request From - Student ID - First/Last Name

i.e.: Change of Internship Provider Request Form - 12345 Jane Doe

Upload Change of Internship Provider Request *

(6 MB Max. PDF only.)

Download Change of Internship Provider Request form

Change of Internship Provider Request Acknoweldgement *

I acknowledge that I have completed all of the Student Section of my Change of Internship Provider Request form

Offer Letter Must Contain The Following:

(Please see sample Offer Letter for more details)

Must be on company's Letter Head
Start & End Date of the Trimester Applying for (Cannot start before first day of trimester and cannot end after last day of trimester)
EIN or E-Verify
Pay Rate: Paid or Unpaid Position
Addresses of where internship will be taken place if different from headquaters
Hours: Part Time (20 hrs or Less) or Full Time (21-40 Hrs)
Goals and Objectives
Supervisor Name, E-mail addressSupplemental Statement
Internship Positions do not offer Benefits
Title and Specific Dutites
Signature on the Offer Letter from Supervisor or Hiring Manager
Supervisor Information (Name, Email and Phone Number)

Important:

Save your file as follow: Offer Letter- Student ID - First/Last Name

i.e.: Offer Letter - 12345 Jane Doe

Upload Offer Letter *

(6 MB Max. PDF only.)

Download Sample Offer Letter

Offer Letter Acknowledgement *

I acknowledge that the Offer Letter being uploaded is true and not altered in any way, shape or form, and has all of the requirements as indicated in the above and in the Sample offer Letter.

Check Your Internship Cooperative Agreement Form:

Is the person who signed the Cooperative Agreement listed on the Offer Letter?

If you answered Yes, Please proceed to Upload
If you answered No, please update your Cooperative Agreement Form with someone who is listed on the Offer Letter, or add the person who signed the Cooperative Agreement to the Offer Letter

Important:

Save your file as follow: Internship Cooperative Agreement Form - Student ID - First/Last Name

i.e.: Internship Cooperative Agreement Form - 12345 Jane Doe

Upload Internship Cooperative Agreement *

(6 MB Max. PDF only.)

Download Internship Cooperative Agreement

Cooperative Agreement Form Acknowledgement *

I acknowledge that I had my Internship provider sign the cooperative agreement form, and the person who signed the Agreement is also mentioned in my Offer Letter

Internship Policy - Click Here to view ITU's Internship Policy.

I have read, understand, and agree to abide by ITU’s Internship Policy. *

I Agree

To the best of my knowledge, I have fulfilled the eligibility requirements to participate in ITU’s Internship program. I understand that if I have not met these requirements, I may be asked to take additional steps to fulfill those requirements or, in some cases, my application may be denied *

I Agree

I understand and acknowledge that an approved internship maybe reduced to half-time if my Term GPA falls below a 3.0 even though my Cumulative GPA is above a 3.0. Furthermore, I understand that if my Cumulative GPA falls below a 3.0, my internship opportunity will be revoked. I acknowledge that if I receive a No Pass (NP) grade for GRN 900 or INT 593 and CFL 591, I may lose eligibility for internship. *

I Agree

I confirm that the offer letter and cooperative agreement attached with this form were both signed by the internship provider. I also understand the provider will receive a confirmation copy of these documents once an internship is approved. *

I Agree

Responsibilities & Assumption of Risk - Release Statement

I acknowledge that my acceptance of an internship offer is a commitment to the university and the provider, and will perform my duties as indicated to the best of my abilities. As internship is credit base, I will register for the appropriate internship course pending departmental approval; pay the appropriate tuition and fees for the credits registered.
I understand that by registering for INT 593, I will be earning credits (only after approval). I understand that I will be charged for this course, as I would any other course taken at ITU.
I agree to inform myself about any rules and/or regulations specific to my work location. I agree to abide by these rules, and I understand that the provider has the right to withdraw the internship opportunity at any time due because of my violation of such rules, disruptive behavior, academic reasons or conduct issues. I understand that this may result in a failing academic grade.
I agree to notify the Internship Coordinator if any disturbing situation should arise at my work location, regardless of its nature.
I understand that I will receive a grade for my participation in the internship program based on the quality and timeliness of submission of a final report.
I understand that ITU and the internship coordinator cannot guarantee the quality of the internship experience as situations beyond their control may arise.
I understand that participation in an internship involves risks that are not limited to traveling to and within, returning from internship locations; foreign political, legal, social and economic conditions; different standards of design, safety and maintenance of buildings, public places and conveyances; and local medical and weather conditions.
I agree to enroll in such medical insurance coverage program as designated by International Technological University for the trimester, unless I opted to waive the insurance as I have my own.

Institutional Arrangement:

I understand that International Technological University (ITU) does not represent or act as an agent for, and cannot control the acts or omissions of, any host employer (provider), transportation carrier, hotel, motel, your organizer or other provider of food, goods or services involved in the internship.
I understand that ITU is not responsible for matters that are beyond its control. I hereby release International Technological University and it's from any injury, loss, damage, accident, delay or expense arising out of any such matters.
Knowing the risks described above, I agree, on behalf of my family, heirs and personal representative(s), to assume all the risks and responsibilities surrounding my participation in the Internship program. To the maximum extent permitted by law, I release, hold harmless and agree to indemnify International Technological University, its Board of Trustees, and its officers, faculty, staff, representatives, volunteers, employees and agents, from and against any present or future claim, loss or liability for injury to person or property which I may suffer, or for which I may be liable to any other person, during my participation in the Internship (including periods in transit to or from any location and/or country where the Internship may be taking place), resulting from any cause including but not limited to ITU, its Trustees', officers', faculties', staffs', representatives', volunteers', employees', or agents' own passive or active negligence or other acts other that fraud, willful misconduct or violation of the law.

I have read, fully understood and agree to abide by ITU's Responsibilities & Assumptions of Risk - Release Statement *

I Agree

Important Note:

Make sure you read and review all forms and submitions to make sure they are complete and correct. All incomplete applications and/or applications with incorrect information will be denied.

International (F-1) Students Only:

I must receive, in writing, practicial training work authorization for my internship from the International Student Office (ISO) prior to employment. I may only partcipate in a for-credit internship. This implies that I must register and pay for the appropriate internship course. I understand that I may not begin my internship before, nor extend beyond, the authorized dates on I-20.

Signature *

Date *

Month Day Year