REQUEST FOR AFFILIATION AGREEMENT

1. Internship Coordinator/Instructor/Dept. making request*:


2. Department-Course #*:
   1. Semester*: (Summer - Session 1, Session 2, Session 3, or Fall, or Spring) Not sure in which summer session the internship falls? Click here for more information.
      

3. 1. Name of agency or company*:
   2. Address*:
   3. On-Site supervisor/contact person*: Phone*:
   4. Title*: E-mail*:
   
   
4. 
   
   1. Student Name *:
   2. Student Email*:
5. Comments:
   

* All items with * are required.