DEPARTMENT OF PROFESSIONALISATION

DPP-FL-0011-02

Authorisation form for the

submission of internship report Page 1 of 1

Certifié ISO 9001 : 2008

I the undersigned
Name ……………………………………………………………………………………………
Surname ………………………………………………………………………………………...
Specialty…………………………………….Level…………………………………………….
Certificate to be obtained………………………………………………………………………..
Academic year…………………………………………………………………………………..
Solicited by Mr/Mrs…………………………………………………………………………….
In his/her capacity of academic supervisor, authorises the deposit of my internship report for
defense.
Theme of the internship report …………………………………………………………………
…………………………………………………………………………………………………...
.......................................................................................................................................................

Academic supervisor attest to the quality of work accomplished by the student and
therefore authorises the deposit of his/her report for defense

View of academic supervisor

FAVOURABLE

UNFAVOURABLE

Signature:………………………………….. Date………………………………………………….

View of the Head of Department

FAVOURABLE

UNFAVOURABLE

Signature:……………………………………. Date …………………………………………………..

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