Internship Information FormAcademic Year: 2015-2016

Reserved for administration use

RC vérifiée : oui valuable jusqu’au………………………. non

All pieces of information given in this form are compulsory for the establishment and management of your internship agreement

To be filled up by the person supervising the internship in the hosting organisation and the student

To be sent to or brought in person at the internship office, room F019, ground floor, UFR IM²AG building

How did you know the internship proposal (displayed offer on UFRIMAG board – web sites – spontaneous application, etc..):

Students details (to be filled up by the student)

Lastname: …………………………………… Firstname: ………………………………………..………………

Student # …………………………Email: …...... ……………………………………………………….…..

Social security membership : ayant droit, étudiant, assuré volontaire ou étudiant étranger

Social security organism : CPAM, MSA, Travailleur indépendant, régimes spéciaux

Program enrolled: ……………………………… Person in charge for this program...... …………..….……………

Hosting organisation details (to be filled up by the organisation)

Corporate name:...... ……………………………represented by …………………………………………………..

Area: …………………...... ……………… Employees: ……………………………………………………….. …….

French companies only: N° SIRET: ………………………………………… Code APE: …......

Address:…………………………………………………………………………………………………………..….….

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Postcode: ………………………………………... City: ……………………………..…………………….……

Country: …………………………………………….….

Person in charge of internship management

Lastname: …………………………………..…………..… Firstname:...... ………………………………………….

Tel: …….....……...…..……… Fax: ……...…...... …...Email : …………………………………..…………………..

Adress:...... ………………………………………………………………….………….…………
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Actual address where the internship is to be done (only if different then organisation address): ………………………………………………….…………......

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Service/department: ………………………………………………………………………………..…………………

Person supervising the internship in the hosting organisation

Lastname: …………………………………..…………..… Firstname:...... ………………………………………….

Position : ………………………………………………………………………………………………………………..

Tel: …….....……...…..……… Fax: ……...…...... …...Email : …………………………………..…………………..

Period(s) of the internship

Full timefrom: …….. / ….... / ….. to: ….. /……./….. how many days each week:......

Part timefrom: …….. / ….... / ….. to: ….. / …. / ….. how many days each week:......

Total duration (full time and part time):……………….. (months) ………….……. (days)

Number of hour per week : 35 Percentage of working hours : 100

Internship agreement

For laboratories associated to UJF, please inform about the credits ( CNRS, UJF, INPG and for INPG) ……………………………………………….……………………………………………….………………….

Fees : No / Yes Amount: …………….… € per mont

Payment : bank transfer Frindge benefits : (meals, lodging, reimbursement)

Fees are compulsory, should you stay 40 days and more in the company or laboratory.

Theme :  computing, data-processing Mathematics, statistics

DETAILS OF THE PROJECT

Title of the project (compulsory) :

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Activities and Tasks

Description of the context and fields of the project, the aims to reach and how you think to reach it

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Objectives and forecasted results : ……………………… ………………………………………………………….

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Technical environment (software, operating system ….) : ……………………………………………..
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Presence of the supervisor in the hosting organisation : - important - not so important - rare

Nom et signature Name and signature

de l’enseignant responsable des stages : of the supervisor in the hosting organisation :

Comments :

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ATTENTION : This internship description form is not an internship agreement.

Street address: 60, avenue de la Chimie - Domaine Universitaire - Saint Martin d’Hères/Gières

Postal address: B.P. 53 - 38041 Grenoble cedex 9 - Tél. : 04-76-63-57-91 - Fax : 04-76-51-43-78