Experience America: Intent to Apply

"On-the-job Training Placement Service"

Before You Fill Out This Form...

Have you taken the time to read the description about our service on this web site? If not, please click on "To the U.S." link below and read about the internship placement services we offer. Then if you are still interested in applying, come back and complete this form. Thanks!

Intent to apply form

Family Name:

First Name:

Street Address:

City:

Country:

Postal Code:

Phone:

country code:

city code number:

E-mail:

Country of Residence:

Birthdate: (mm/dd/yy)

/ / 19

Are you interested in applying for the Self-Arranged Internship Program?	yes no
If yes, please give us the name of the company, address, name of the supervisor, and telephone number, and the dates of your internship.
Are you interested in applying for the Personalized Internship Program?	yes no
What is your area of interest/specialization?
Are you currently enrolled in an English language school?	yes no
If yes, what is the name and phone number of the school?
Are you currently attending a U.S. college or university?	yes no
If yes, what is the name of the college or university?
Questions or Comments: