Ursinus College greatly appreciates your participation in the Extern Program. Please submit the following information in order to register

Employer Information:

*First Name :     

*Last Name :     

*Preferred Email Address :     

*Preferred Phone :      EXT :

*Please indicate your status :     

Alumni Class Year/Child's Class Year :     

If alumni, please indicate your undergraduate major(s) :   


Externship Location Information :

*Organization :     

*Sponsor's Title :     

*Sponsor's Department :     

*Business Address 1 :     

Business Address 2 :     

*City :     

*State :     

*Zip Code :           

Web Address :     

*Work Phone :      EXT:  

*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)? 

    *No.of days: 

*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