Southeastern Community College


Summer Externship Application

* denotes required information.

* First Name:

* Middle Initial: enter 'X' if no middle initial

* Last Name:

* E-Mail Address:

* Street:

* City:

* State:

* Zip:

* Phone:  Please include area code, and enter only numeric digits. Example 3197522731

* Preferred Method Of Contact:  Phone    Email

* School Name:

* Grade Taught:

* Subject Taught:

Preferred Externship Type (i.e. Web Design, Welding, Banking:

Do you have a possible location in mind? If so, where?:

Please list any special certifications or training that you have in your field:

Identify how you would apply your experience in an externship to the classroom:

Are there any specific goals that you want to meet with an externship experience?

You may also print and send completed application by April 3, 2017 to: Southeastern Community College, Attn: Leanne Krogmeier, 1500 W Agency Road, West Burlington, IA 52655, Fax: 319-752-4957 or email to lkrogmeier@scciowa.edu.


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