Student Name:
Degree Sought
Work Experience Program:  Internship  Co-op
Company:
 Address 1:
Address 2:
City: State: Zip:
Contact Person:
Contact's Title:
Type of Business Biotechnology Computer Software
Educational Technology Electronics
Energy Engineering Consulting Firm
Environmental Engineering Materials/Chemical Engineering
Mechanical Products Parts Supplier
Other (specify) 
Project Name: 
Project Duration (months): 
Description of Project (be brief):
Technical Impact (what was accomplished):