Internship Site Identification Form

Provide all required information.

Date Date * / MM / DD YYYY
Student Name Student Name * First Last
Phone Phone * - ### - ### ####
Student Local Address Student Local Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Student Permanent Address Student Permanent Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
E Number *
Email
Semeter Interning *
Site #1 Name of Agency
Site #1 Site #1 *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Provide the information requested below for a possible internship site you have identified and investigated. You ARE NOT required to identify more than one site but are permitted to identify up to three. Use the next 2 address boxes if you have more than one site of interest.
Name of Contact Person for Site #1 Name of Contact Person for Site #1 * First Last
Email of Contact Person at Site #1
Phone for Contact Person Site #1 Phone for Contact Person Site #1 - ### - ### ####
Reasons for identifying this site: *

Provide a brief rationale or reasons why you are interested in this site.
Additional Information for Site #1

Indicate here if an on-line application is available for this site, if you have already completed the on-line application, and provide the web address where the application can be found.
Site #2 Name of Agency
Site #2 (Not Required) Site #2 (Not Required)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Name of Contact Perosn for Site #2 Name of Contact Perosn for Site #2 First Last
Email of Contact Person for Site #2
Phone for Contact Person Site #2 Phone for Contact Person Site #2 - ### - ### ####
Additional Information for Site #2

Indicate here if an on-line application is available for this site, if you have already completed the on-line application, and provide the web address where the application can be found.
Reason for Selecting this Site:

Provide a brief rationale or reasons why you are interested in this site.
Site #3 Name of Agency
Site #3 (Not required) Site #3 (Not required)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Name of Contact Person for Site #3 Name of Contact Person for Site #3 First Last
Email of Contact Person for Site #3
Phone for Contact Person Site #3 Phone for Contact Person Site #3 - ### - ### ####
Additional Information for Site #3

Indicate here if an on-line application is available for this site, if you have already completed the on-line application, and provide the web address where the application can be found.
Reason for Selecting this Site:

Provide a brief rationale or reasons why you are interested in this site.
Internship Resume Attachment *

Attach a copy of your Internship resume. Be sure to include your name as the name of the file.
Example: Phillips Resume.docx