APPLICATION FOR UNDERGRADUATE FIELD EXPERIENCE
College of Management
University of Wisconsin-Stout
I. PERSONAL INFORMATION
Name
Student ID#
Address while on field experience
City
State
Zip
Home Address
City
State
Zip
Phone # on Field Experience
Home Phone #
Major
Email Address
Minor/Concentration
II. EMPLOYER INFORMATION
Supervisor’s Name
Supervisor’s Title
Company Name
Address
City
Phone
Your job title
Dates of Employment:
to
State
Zip
Planned # of hours per week
Brief job description (duties and responsibilities)
Have you previously worked for this employer?
If yes, in what capacity?
Yes
No
III. LEARNING OBJECTIVES YOU HOPE TO ACHIEVE
The purpose of this section is to encourage you to stop and reflect what you want to
achieve from this experimental learning course prior to undertaking it. You should
realize that is a possibility that not all of the objectives stated will be achieved, and
others objectives may develop.
1. List the major and minor learning objectives you plan to obtain from this field
experience. Please number and describe separately. Be specific to the skills,
knowledge, attitude, etc. you hope to develop or improve from this experience
either directly or indirectly.
2. Describe how you hope to achieve the above objectives.
D. APPROVAL FORM
1. I accept the responsibility of coordinating this student's work experience.
______________________________________________________________________
Signature of Experience Coordinator
Date
2. I confirm that this Field Experience relates to our department.
______________________________________________________________________
Signature of Department Chair
Date
3. I authorize the use of these credits in filling the requirements of the
_________________________________
(Degree major or minor)
as _____________________credit.
(required or elective)
Signature of Program Director
Enrolled ______________Fr
Date
So
Jr
Sr
___Only course taken ___ Add card
_______________________________
Course number (2 credits)
__________________________
Semester Enrolled
OR if taken 1 credit in different semesters
_______________________________
Course number (1 credit)
__________________________
Semester Enrolled
_______________________________
Course number (1credit)
__________________________
Semester Enrolled
Approval letter received from employer ______________________________
Periodic Learning Reports (2) ____________
Evaluation received from supervisor___________
_____________
Final Report___________
Return application form (with the required signatures) to: Sue Jasperson
280 TW, UW-Stout, Menomonie, WI 54751
ph: 715-232-2696,
fax: 715-232-1274
e-mail: jaspersons@uwstout.edu