*Sponsor's Title :
*Sponsor's Department :
*Business Address 1 :
Business Address 2 :
*Zip Code :
Web Address :
*Work Phone :
*Work Email :
Briefly describe your organization and job responsibilities :
*List what the Extern will learn/observe
How many days will the Externship be ? (Externships are 3-5 consecutive days) and which days during Extern weeks (January 3-13 2017)?
*How many Externs are you willing to Host?
if you are hosting more than 2, please enter number in the textbox :
*Have you received approval (if required) from your supervisor/administrators to be an Extern Sponsor?
*If No, please indicate when and how you will be obtaining this approval.
*Does your organization require paperwork/forms/agreements/clearances to be completed by the College or Student Extern prior to participating in the program?
*If Yes, please describe below in as much detail as possible.
* Required Fields