First Name

Last Name

Title

Mobile

Work Phone:

Email

Company

Street

City

State/Province

Zip

Country

Billing Contact Name:

Billing Email Address:

Billing Street:

Billing City:

Billing State:

Billing Zip Code:

Number of interns to host:

Description of intern interest:

Type of intern you would like to host:

Type of student you would like to host:

Assigned campaign/project:

Goal of the Campaign/Project:

Workers/Members and current problems:

Stage during the internship:

Locations the intern will work from:

Location accessible to daily commute:–None–YesNo

Intern Role:

How will the research be used:

Expectations of Student Intern:

Intern’s special skills:

Please select any language requirements:SpanishMandarinCantoneseTagalogVietnameseFarsiOther

If other, please specify language:

Selected language required or preferred:–None–RequiredPreferred

Car provided by the intern is:

Willing to provide a car:–None–YesNo

Willing to relocate/provide housing:–None–YesNo

Prefer to host graduating senior:–None–YesNo

Hosting longer than 8 weeks or hiring:–None–YesNo

Other staff and description:

Kind of workspace and location:

Supervisor different than above:–None–YesNo

Site Supervisor First Name:

Site Supervisor Last Name:

Site Supervisor Title:

Site Supervisor Email:

Site Supervisor Work Phone:

Site Supervisor Cell Phone:

Supervisor Location and same as intern:

Supervised Labor Summer intern before:–None–YesNo

Description of supervisor experience:

Supervisor’s frequency of contact:

Campaign/Project details:

Hosted a Labor Summer intern before:–None–YesNo

Organization Details:

Interested in scholarship application:–None–YesNo

Amount Organization able to cover:

Hosting feedback: