Employer Enrollment Form
Please complete this form then click "Submit" to register!!!
Name: Title:
Company/Organization:
Address: City: Zip:
Telephone: Ext: Email:
Fax: Website:
Type of Organization: Business Non-Profit Other
Brief description of organization:
What position(s) and how many opportunities might you make available?
General Description of Performance Requirements:
Please indicate the type of internship(s) available:
Paid Unpaid Both Begins Non-Paid/May Change Funding Stipulation
If paid, please indicate rate range:
Opportunities available to the following grade level(s):
9th 10th 11th 12th Community College
Other Are there any minimum age requirements?
What is the duration of the internship opportunity? Please indicate start and end dates as appropriate.
Please indicate when these opportunities might be available:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
0-2 hours/day 2-4 hours/day 4-6 hours/day 6-8 hours/day
General Comments or Questions About Internships:
Please indicate the best time and method (i.e. Fax, Phone, e-mail) to contact you: