Practicum Application - Site

Username/Email Address: *

Agency/Organization Name: *

Street Address: *

City: *

State: * Alaska Alabama Arkansas Arizona California Colorado Connecticut Dist of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Country: *

Zip: *

International address

Mailing Address is different than above

Web Address:

What is the mission statement of your organization and your department/division/unit/etc?*

Please describe any particular population groups you serve:

Do you have insurance to cover any unforseen accidents?

Which of the following describes your organization? (check all that apply):

• Educational, Literacy, and Library Institutions
• Federal government agency
• Health advocacy/policy
• Health care facility
• International agency/organization
• Local or State government agency
• Private for-profit agency
• Private not-for-profit agency
• Research institution
• Other (please specify):