You need one submission for every internship during this time frame. Student Work Verification Form 1. Student Name * Please include your first, middle and last name. 2. Today's Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 3. Work Period Included in this Form Please provide the month of your start and end dates. NOTE: One internship and one company per form. If you worked for two companies, each for five weeks over the period of one summer - you need two forms. Start Month * - Select - January February March April May June July August September October November December Start Year * - Select - 2023 2022 2021 2020 2019 2018 2017 2016 End Month * - Select - January February March April May June July August September October November December End Year * - Select - 2023 2022 2021 2020 2019 2018 2017 2016 4. Total Hours worked during the period noted above * 5. Student's Email * Must be an @purdue email address. 6. Student's Phone Number * 7. Student Classification * Freshman Sophomore Junior Senior 8. List five activities that you regularly performed during this period * Examples: updating employee records, sales, supply chain analysis, onboarding activities, daily reports, assisted in interviewing, etc... 9. Explain how your work experience related to material presented in the classroom * 10. Is there anything you wanted to do, learn or experience during this work experience that you were not able to? * 11. Has this work experience changed your mind about working in your major or a specialty within it? If yes, please explain. * Company Information 12. Name of Company * 13. Address of Home/Main Office * Please use the address of the office that you worked in or that your jobsite/project reported to. 14. Type/Sector of Company * 15. Location of office or jobsite where you worked if different than item # 13 above * 16. Name of supervisor that will be able to verify your work * 17. Supervisor's email * You must enter a valid e mail address and phone number in order to record and verify your hours. Please take the time to find and then confirm a correct email for your supervisor. 18. Supervisor's phone number * 19. Salary/hourly rate * 20. Did you receive a housing allowance? * - Select - The company provided me with housing The company provided an allowance for housing The company did NOT provide housing or a housing allowance 22: Did you receive any other financial assistance from the company for your internship? Please select all that apply: * No A Per diem allowance Gas reimbursement or mileage allowance Use of a company vehicle Paid for airfare or travel to/from the internship location Other Leave this field blank
