NYU Wagner

Professional Experience Requirement Approval Request Form

All fields marked with are required.

1. Please complete all information.
2. You will be contacted within 10 business days.
3. Once you finish your 280 hours, fax a completed Employer Documentation Form to 212-995-4165, attention: Nancy Diaz.

1. CONTACT INFORMATION

Questions on completing the PER Approval Request form should be directed to Nancy Diaz, who can be contacted at 212-998-7506 or via email at nancy.diaz@wagner.nyu.edu.

First Name:
Last Name:
Date:	mm/dd/year
University ID Number:	N
Local Address:
Address Line 2:
City:
State:	Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Caribbean Military Delaware District of Columbia European APO/FPO Far East APO/FPO Fed. States Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota N. Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Permanent Address:
Day/Evening Telephone:
Email :

2. DEGREE PROGRAM INFORMATION

Degree Program:
Choose one... MPA - Public/Nonprofit Mgt. & Policy MPA - Health Policy & Mgt. Master of Urban Planning

Specialization:
Choose one... MPA - Management MPA - Policy MPA - Finance MPA - International MUP - Environment, Infrastructure & Transportation MUP - Economic Development and Housing Policy MUP - International Development Planning OTHER (Describe below)

Other:



Expected Date of Graduation:
January May September Year... 2010 2009 2008 2007

3. EXPERIENCE INFORMATION

Position Title:
Organization:
Direct Supervisor's Name:
Please list the start and end dates for the position. If this position has no end date, please list the date you started at the position, and write "Ongoing" in the "End" field.
Dates of Tenure at Position:
Start: mm/dd/year   End:   mm/dd/year
Please list the total number of hours you will have completed by the position's end date. If this position has no end date, please indicate whether the position is "Full-Time" or "Part-Time"
Position's Total Hours:
Expected Total Hours Worked: Hours/Week: X  #/Weeks: = Total Hours:

Description of Work Performed:
Relevance of Experience to intended Program of Study: