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....--------------------~-------------------------· ATLAN TA URBAN In te rn ship Assignme nt Form CORPS r Date Urban Co rp s Rep res e nt at iv e Name of Host Org aniza ti o n

Or g an i z at i o n a I Unit o f Proposed Assignment

Address Assi gnment Locat ion ( : f differ en t f rom above) Perso n Respons ibl e for Intern s hip

Tit I e ____________________ Function of Organizational Unit

Teleph o ne No. ____________

Int e rnship Project Title (Outline o n Revers e Si de) Begi nni ng Date

'-- Full Tim e Ending Dat e Part Tim e Special Assig nm ent Cond iti ons Approx.

Hours Per Week

Experience, Sk ills, Training or Other Qualificati o ns Desired: Intervie w Req ueste~: Name of I nt e rvie wer

Location

Phone-----------Req uest for assignment of an Atlanta Urban Corps intern in the descr i bed

position on the reverse side is hereby approved . I hereby certify that the assignment of an Atlanta Urban Corps intern into thi s position wi I I not result in the displacement of a regular worker or imp air existing contracts for servic es. S i gna - ure Title Date �Project Out Ii ne De sc ribe briefly in terms of how the task serves the purposes of the organization: Specific objectives of internship project: Planned orientation and approaches: To Be Completed By Atlanta Urban Corps Educational Counselor -------,-N,-a_m_e________ Title

Technical Representative Name Phone Address Phone Address

Intern ---------,N~a_m_e___________ Address

Titl e Co ll ege Ph o ne

Approved For Atlanta Urban Corps _______________ Signature Date �