PETITION FOR CREDIT FOR:	_____INDEPENDENT STUDY
	_____INTERNSHIP/PRACTICUM
	_____TEACHING EXPERIENCE

To be completed by department chair:
Department ______ Course No. ______ Sequence No. ______
Credit Hours ______ Fall 20 ________ Spring ________
Student is Registered _________ Will add ________

To be completed by student:
Name ______________________ ID# _______________ Class __________
Address _________________________________________
Major(s) ___________________ Minor(s)____________________

Previous or Concurrent Credit for:

Independent Study	______ credits in _____ Dept. (6 credits maximum in one dept--9 credits total
Internship	______ credits in _____ Dept. (6 credits maximum)
Travel Program	_______ credits in summer of _______
Other	_______ credits in ____________
Total	_______ credits (may not exceed 18)

Prior Coursework or Other Relevant Background:

Nature of the Project: (attach a separate sheet if appropriate)

(For internship, indicate sponsoring organization, nature of work, nature of supervision. For independent study, provide tentative bibliography, outline of proposed research, etc.)

Justification for Amount of Credit Expected:

(Independent Study: approximately 3 hours per week per credit; internship: approximately 4 hours per week per credit.)

Evaluation Criteria and Procedures:

Student signature ___________________________ Date _________

Approvals:

Field supervisor: if internship ____________	Date ________
Faculty Supervisor ____________	Date ________
Chair's Approval ____________	Date ________

Approved as major/minor elective ________ Free credit ________

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