• Students
  • Fulfillment Verification Form

PROFESSIONAL EXPERIENCE REQUIREMENT

Please complete the following form to document your progress towards fulfillment of your Professional Experience Requirement (PER).

  • Please submit a separate form for each position that you would like to have counted towards your PER
  • If there are any complications with the form(s) that you've submitted, you will be contacted within 10 business days

All fields marked with are required.

1. Student Information

First Name:
Last Name:
Date:
University ID Number:
N
Day/Evening Telephone:
Email:

2. Degree Program Information

Degree Program:


Specialization:


Other:



Expected Date of Graduation:

3. Summary of the Position to be Counted Towards your PER

Position Title:
Organization:
Direct Supervisor's Name:
star
Supervisor's Title:
star
Supervisor's Telephone: star
Supervisor's Email Address:
star
Org. Street Address:
star
Org. City:
star
Org. State:
star
Org. ZIP Code:
star
Org. Country:


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 click "Ongoing" checkbox.

Start Date: mm/dd/yyyy  
End Date: mm/dd/yyyy
Ongoing?


Please indicate whether the position is "Full-Time" or "Part-Time" in the space provided below.
Position Type: star


Description of work performed:
star

Relevance of position to your
degree program and specialization:

star

4. Documentation of PER Hours

Please calculate the total number of hours that you have completed in this position. (Note: any hours completed prior to your first semester at NYU Wagner will not be counted towards your PER).


Expected Total Hours Worked: star
Hours/Week: X  #/Weeks:

= Total Hours:

If you have not completed a minimum of 280 hours in this position (while enrolled at NYU Wagner), please complete a separate Fulfillment Verification Form for all other degree relevant positions that you intend to have counted towards your PER.


Please check the box below if you are an international student (in lawful F-1 or J-1 Visa status sponsored by NYU) and received approval from OISS to use this position for Curricular Practical Training
International Student (CPT):