Experience America: Host company request form

"On-the-job Training Placement Service"

Before You Fill Out This Form...

Thank you for your interest in our Internship Program. Please take a minute to provide the following information about your company. (If you are a student/applicant wishing to come to the U.S., please do not fill out this form. This form is for employers in the United States only!

Host Company request form

Your Name :
Title :
Company :
Address :
City :
State :
Zip Code :
Telephone :
Fax :
E-mail :
I am interested in hosting an intern in the following occupational field :
Preferred Duration of Hosting :
Estimated Salary/Compensation :	$ paid/per hour non-paid
I learned of Experience America from :
We have already identified the following individual for an internship in our company .
Name of intern :
Country :
Dates of internship :	thru
E-mail address :