NAME: NAME:
For the month of Year For the month of Year
MORNING AFTERNOON MORNING AFTERNOON
DAY SIGNATURE DAY SIGNATURE
TIME TIME TIME TIME TIME TIME TIME TIME
IN OUT IN OUT IN OUT IN OUT
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
I certify upon my honor that the above is true I certify upon my honor that the above is true
and correct report of the hours of worked and correct report of the hours of worked
performed, a record of which was made daily performed, a record of which was made daily
at the time of arrival and departure. at the time of arrival and departure.
Signature of Intern Signature of Intern
Certified as to prescribed office hours Certified as to prescribed office hours
Supervisor Supervisor