Request For Affiliation Agreement

Request For Affiliation Agreement

Request For Affiliation Agreement
This request is only for non-clinical placement of students in internships. For clinical agreements, please contact your department for proper procedure.

Internship Coordinator/Instructor/Dept. making request:
Email:
Dept./Course #:
Please select the session that the Affiliation Agreement is required for placement.
Session:
Use Ctrl or Shift keys to multi-select.
Name of Agency or Company:
Company Address
On-Site Supervisor/Contact Person
Supervisor's Phone
Supervisor's Title
Supervisor's E-Mail
Student Name
Student's E-Mail
Comments or Questions:
Please click on "save and continue" to submit this form. If you have any difficulty completing this form contact internships@bloomu.edu

Fenstemaker Alumni House • (800) 526-0254 • (570) 389-4058 • FAX: (570) 389-4060 • alum@bloomu.edu