$supname

Address:
$supaddress1
$supaddress2

City:
$supcity

ZIP Code:
$supzip

Business Phone:
$supphone"; else $supervisor = "N/A"; print "Thank you; your application has been submitted."; $headers = "MIME-Version: 1.0\r\n"; $headers .= "Content-type: text/html; charset=iso-8859-1\r\n"; $headers .= "From: $name <$email>\r\n"; $message = "Full Name:
$name

Address:
$address1
$address2

City:
$city

ZIP Code:
$zip

Expected Graduation Date:
$gradsem $gradyear

Home Phone:
$hphone

Work Phone:
$wphone

I am applying for practicum for:
$applysem $applyyear

I am making application for the following course:
$course

I am planning for placement in the following setting(s):
state agency public school university state: $placement1
hospital/school: $placement2
private hospital/school other: $placement3

If you have made prior arrangements with a practicum/intern site, list the following information:
$supervisor

If you have not made prior arrangements, list the geographic area and suburban area you would prefer:
$areapref"; $subject = "$pracint Application"; mail($toemail, $subject, $message, $headers); } else { ?> Full Name:


E-mail Address:


Address:



City:


ZIP Code:


Expected Graduation Date:
Fall Spring Summer 2011 2012 2013 2014

Home Phone:


Work Phone:


I am applying for practicum for:
Fall Spring Summer 2012 2013

I am making application for the following course:
EDP 5389 A (1st 200 clock hours, practicum) EDP 5389 A (2nd 200 clock hours, practicum) EDP 5389 A (3rd 200 clock hours, practicum) EDP 6300 A (1st 600 clock hours, internship) EDP 6300 B (2nd 600 clock hours, internship)

I am planning for placement in the following setting(s):
state agency public school university state
hospital/school
private hospital/school other (provide information below)

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If you have made prior arrangements with a practicum/intern site, list the following information:
Site director/supervisor name:


Address:



City:


ZIP Code:


Business Phone:

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