Appendix III

Form 3

INTERNSHIP SITE CONFIRMATION

AMERICAN UNIVERSITY OF RAS AL KHAIMAH

P.O. Box: 10021
Ras Al Khaimah, United Arab Emirates
Telephone No. +971-7-2210500
Fax No. +971-7-2210300

Section A: Student Information during Internship

What contact number during internship?
Local Phone # (H): ( ) ____________________ (W): ( ) ____________________

Cell Phone #: ( ) _______________________

AURAK E-Mail: __________________________________@________________________

Section B: Internship Site Information

Please provide the following information about the internship site.
Company Name: ___________________________________________________
Department (if applicable): _____________________________________________
Address: _________________________________________________________
_____________________ _____________________ ______________________
Company Main Phone #: Fax: ( ) Company Webpage address:

Section C: Site Supervisor Information

Please provide the following information about your Supervisor.
Supervisor: ___________________________________________________________
Supervisors Title: _____________________________________________________
Supervisors Phone #: _________________________ Fax: ( ) ______________
Supervisors E-Mail: _________________________________@________________

Section D: Internship Duration

Intern Starting Date: ____/ ____/ 20___ Intern Ending Date: ____/ ____/ 20___

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 Section E: Type of Internship Position: (Please check ( ) the appropriate box)
Voluntary *Paid (as a paid position, the rate is AED______ per _____)

Section F: Intern Job Description

Attach a copy of the job description which lists all the activities and responsibilities
associated with this internship position.

Section G: Learning Objectives Agreed to by the Intern and Site Supervisor

List three to five learning objectives which describe what you want to learn from the
internship experience. Objectives should be concise, measurable (e.g., identify, improve,
define, compare, apply, understand, develop, write) and attainable actions or behaviors
related to particular duties of the internship. Previously stated objectives on the Confirmation
Eligibility Form submitted earlier by the student may have to be revised to reflect the
learning opportunities actually available at the site. For each objective please describe the
relevant strategy (i.e. specific processes or tasks) that will help the intern meet their
objectives. Attach learning objectives and associated strategies on a separate sheet of paper.

Section H: Documentation
Attach the following documents to this application:
Valid photocopies of health insurance ID card (front and back);

SIGNATURES
___________________________________________ ______________/____ / 20____
Intern Date
___________________________________________ ______________/____ / 20____
Site Supervisor Date

Please return to the Faculty Internship Advisor upon completion. Thank you.

__________________________________________ _____________ /____ / 20____

Faculty Internship Advisor Date Reviewed

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