Application for Employers Interested in Hosting EHS Interns

* Required field

Facility Information

Name of Facility:*

Address:*

City:*

State:*

Zip:*

Other Locations:

Website Address:

Phone:

Contact Person

First Name:*

Last Name:*

Phone:

Email:*

Facility Description:

No. of employees in the department:

Is your location accessible by T?*

Yes No

Intern's Supervisor

Email:*

Phone:

Educational background of supervisor (brief)

Program Details

Do you have an existing intern program?*

Yes No

How many interns do you accept per semester?

Fall:

Spring:

Summer:

Intern's responsibilities and/or specific projects(Provide a weekly plan if possible):

Educational Goals and Career skills acquired by intern:

Please answer the question below. This is to ensure that this form is submitted by a person rather than a robot.*
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