INTERNSHIP PROGRAM
Employer Request for Intern
Coordinator: Christy Kloezeman
Thank you for your interest in our Internship Program. To enable us to assist a qualified intern at your work location, please provide the following information:
Company Name
Address
(Street address)
(city)
(zip)
Contact Person
(Last)
(First)
(title)
Phone
Site Supervisor
INTERN POSITION AVAILABLE
Today’s Date
Days Preferred
Time of Day Preferred
Total Hours Desired
Start Date
Do you offer compensation for additional hours? (A minimum of 54 unpaid Internship hours required
Yes No
Rate of Pay
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
DUTIES TO BE PERFORMED/ SKILLS TO BE LEARNED:
Academic Background Desired:
Skills Required:
Additional Comments: