SEMESTER (FILL IN YEAR AND CIRCLE SEMESTER REQUESTED)

 SPRING, 200____     SUMMER, 200____    FALL, 200____
 

__________________________ Date Submitted ________________
(Advisor's Signature)

________________________________________________________________
NAME      Last          First              MI                                  Social Security No.

___________________________________________________________________
Street Address                                                  City                  State          Zip

________________________________________________________________
Home Telephone                 Work Telephone No. (if applicable)

     PREFERRED PRACTICUM SITE          NAMES, ADDRESSES AND PHONE
                                                                 NUMBERS OF  ON-SITE SUPERVISORS

1.     ____________________________ ______________________________________
        ____________________________ ______________________________________
        ____________________________ ______________________________________

2.     ____________________________ ______________________________________
        ____________________________ ______________________________________
        ____________________________ ______________________________________
 

APPLICANT: WRITE COMMENTS OR REQUEST BELOW
 
 
 

This application must be submitted by September 15 for Spring Practicum, February 15 for
Summer Practicum, and June 15 for Fall Practicum.
Submit this completed form to the Counseling Psychology Practicum Coordinator (Bridges)

Department of Counseling, Educational Psychology and Research
Counseling Psychology
The University of Memphis, 2002