Evaluation of 
Internship/Clerkship 
Services Request Form

Please fill out the Evaluation of Internship/Clerkship Service Request Form to the best of your knowledge. Records & Registration will reach out if any additional information is needed. Students may reach out to Records & Registration at mramos@cavallauniversity.education.

Schedule Submission Date

Type of Evaluation

Student Name

Academic Status

Student Email Address

Student ID

Student Contact Number

Date of Birth

Student Full Address

What is the Name of the Employer?

Start Date of Internship/Clerkship

End Date of Internship/Clerkship

Total Number of Internship/Clerkship Hours Completed

Supervisor Name

Supervisor Telephone Number

Supervisor Email Address

Describe the Type of Work Performed

Comment/Feedback/Suggestion

E-Signature

Date of Attestation

Evaluation of Internship/Clerkship Services Request Form

Thank you!

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