Online Intern Request Form

Internship Program:		School-Year Work Exposure Occupational Skills
Employer Information
Company Information
*Company Name:
Company web address:
*Number of Employees:
*Industry/type of business:
Primary Contact Information
*Primary Contact First Name:
*Primary Contact Last Name:
*Primary Contact Job Title:
*Address:
Suite/Apt/Floor:
*City:	State: Zip:
*Primary Contact Phone:	Fax:
*Primary Contact E-mail:
Secondary Contact Information
*Secondary Contact First Name:
*Secondary Contact Last Name:
*Secondary Contact Job Title:
*Secondary Contact Phone:
*Secondary Contact E-mail:

Intern Information
*Title/Type of position:
*Number of Interns/ Available positions:
Ideal working hours: (i.e. 9am - 1pm)*
*Days of the week:	Monday Tuesday Wednesday Thursday Friday Saturday Sunday

*Dress Code:	Business Casual Business Professional Casual Company Uniform School Uniform Acceptable
*Referred by:	Chamber of Commerce (Working Solutions) City of Philadelphia Philadelphia Academies United Way PYN Staff YPN Other:
Please describe the Intern’s Duties (or upload a job description below):

Please indicate if you have already identified interns or would like them to come from a specific School/program (e.g. Philadelphia Academies, Inc.; vocational/technical schools, etc.):

*What additional documentation/clearances will be needed (to be coordinated and paid for by the employer)? Check all that apply (leave blank if none):
Criminal Background:
Child Abuse Clearance:
Drug Test:
Physical:
Other:

Upload Job Description (optional):
	Word Documents Only

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