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