Today's Date
*
-
Month
-
Day
Year
Date
WIU ID #
*
E-mail
*
Last Name
*
First Name
*
Initial
Permanent or Home Address
*
City
*
State
*
Please Select
AL Alabama
AK Alaska
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
FL Florida
GA Georgia
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
E Maine
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH Hew Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
OH Ohio
OK Oklahoma
OR Oregon
PA Pennsylvania
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VA Virginia
WA Washington
DC Washington D.C.
WV West Virginia
WI Wisconsin
WY Wyoming
Other
Zip
*
Home Phone
*
Current or WIU Address
*
City
*
State
*
Please Select
AL Alabama
AK Alaska
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
FL Florida
GA Georgia
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
E Maine
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH Hew Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
OH Ohio
OK Oklahoma
OR Oregon
PA Pennsylvania
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VA Virginia
WA Washington
DC Washington D.C.
WV West Virginia
WI Wisconsin
WY Wyoming
Other
Zip
*
Cell or WIU Phone
*
Major
*
Please Select
Agricultural Business
Agricultural Science
Agriculture-Teacher Education
Other
Minor
Currently Completed Total Semester Hours
*
Major GPA
*
Cumulative GPA
*
Planned Graduation Semester
*
Please Select
Fall
Spring
Summer
Planned Graduation Year
*
Please Select
2015
2016
2017
2018
Are you a transfer student
*
Yes
No
Name of School Transferred From
Anticipated Internship Start Date
*
-
Month
-
Day
Year
Date
Anticipated Internship End Date
*
-
Month
-
Day
Year
Date
Internship Semester
*
Please Select
Summer
Fall
Spring
No. of hours to be enrolled (4-12)
*
Mark the area of agriculture in which you are interested for the internship:
*
Ag Finance
Ag Mechanization
Ag Management
Ag Marketing
Agronomy
Animal Science
Forestry
Horticulture/Conservation
Other
List Two Specific Career Choices
*
Describe what experience and/or training you hope to gain from participation in the internship program .
*
Describe the special project you are interested in doing during the internship .
*
Information for cooperating agricultural business or agency you wish to work with:
Internship Firm
*
Firm Address
*
Firm City
*
Firm State
*
Please Select
AL Alabama
AK Alaska
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
FL Florida
GA Georgia
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
E Maine
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH Hew Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
OH Ohio
OK Oklahoma
OR Oregon
PA Pennsylvania
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VA Virginia
WA Washington
DC Washington D.C.
WV West Virginia
WI Wisconsin
WY Wyoming
Other
Firm Zip
*
Internship Supervisor (if known)
Firm or Supervisor Phone
Supervisor E-mail
*
If known, provide the contact information where you can be reached during your internship:
Intern's Work Address
Intern's Work Phone
Intern's Work E-mail
Have you worked for (or are currently working for) this agricultural business or agency?
*
Yes
No
Describe the previous or current experience
Have you have any health issues that the employer should know about before you start?
*
Yes
No
Briefly describe the health issue(s)
Submit
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