Internship+ Application

Full Name *

First Name Middle Name Last Name

Company *

Company Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

University/College *

Major/Area of Study *

If you have any co-majors or minors please list them here as well.

Email *

Alternate Email

Phone Number *

Area Code Phone Number

Internship Start Date *

Month Day Year

Internship End Date *

Month Day Year

Intern Shirt Size *

Please list any special accomodations needed (dietary or otherise)

Employer Contact Name *

Employer Contact Title *

Employer Phone Number *

Area Code Phone Number

Employer E-mail *

I would be willing to host a luncheon event at our site for the interns. Please contact me to coordinate.

Yes No

I would be willing to provide a leadership trainer and content. Please contact me to coordinate.

Yes No

***ANY CHANGES TO CONTACT INFORMATION MUST BE PROVIDED TO THE GROWTH ALLIANCE***

By participating in the Internship+ Program, I (Intern) hereby grant permision to the Greater Fort Dodge Growth Alliance to use my photography on its website or in other printed publications without further consideration. I also acknowledge that the Greater Fort Dodge Growth Alliance may choose not to use my photo at this time, but may do so at its own discretion at a later date.

Intern Signature

Clear

Date

Month Day Year

Employer Signature

Date

Month Day Year