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:
required
Email:
Dept./Course #:
required
Please select the session and year that the Affiliation Agreement is required for placement.
Session:
required Use Ctrl or Shift keys to multi-select.
Year
Name of Agency or Company:
Company Address
required
On-Site Supervisor/Contact Person
required
Supervisor's Phone
Supervisor's Title
required
Supervisor's E-Mail
required
Student Name
required
Student's E-Mail
required
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