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INTERNSHIP ATLANTA URBAN CORPS 30 Courtland Street, N.E . Atlanta, Georgia 30303 ASSIGNMENT 3 INTERN NO . 4 INITIAL ASSIGNMENT NAME REASSIGNMENT FART TIME ADDRESS
SUMMER
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AGENCY
7
COORDINATOR
9
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10
ADDRESS
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ASSIGNME~T
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11
NATURE OF ASSIGNMENT
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TO BE COMPLETED BY AGENCY COORDINATOR
STUDENT
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IMMEDI ATE SUP[RVISO R
[]ACCEPTED
ASSIGNMENT (NAME OF CENTER)
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ASSIGNMENT HOURS
TO
F'ROM
DDECLINED
MON
ASSIGNMENT ADDRESS
UNACCEPTABLE
REMAR KS
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TUES
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WED
THURS
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FRI
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SUN
TO BE COMPLETED BY INTERN IF DECLINING ABOVE POSITION
D
I decline this assignm e nt and wish to be re assigned because:
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D I wish lo withd raw from the . URBAN CORPS. (s e e ite m 5 on reverse) DISTR I BUT I ON : WHITE , CANA ·R Y ·a. GREEN - URBAN CORPS FIN K - AGENC Y COORDIN A TOR AGENCY COORDINATOR BLUE - INTE~NS RECORD FORM UC - 4 9 / 67 M-822278 �INSTRUCTIONS: TO URBAN CORPS INTERN: l. This is your intern assignment. In accordance with your stated preference, you have been assigned to the position described in Box 11 on reverse side. 2. You MUST contact the COORDINATOR named in Box 8 immediately to arrange for an interview, at which time the exact nature of your assignment will be outlined. 3. Bring all five copies of this form with you to the interview . DO NOT SEPARATE THEM. At · your interview, the agency coordinator will fill out Boxes 13 through 21. 4. The agency coordinator will retain the pink copy . You will remove the blu·e copy for your records. You MUST return the other three copies to THE ATLANTA URBAN CORPS, 30 "Courtland Street, N.E., Atlanta, Ga . 30303: IMPORTANT--NO PAYROLL WILL BE PROCESSED UNTIL THESE FORMS ARE RECEIVED BY THE URBAN CORPS OFFICE. 5. If, before the interview, you decide that you do not want this assignment, check space in Box 22 and state your reasons. If you wish to withdraw from the URBAN CORPS, check the space in Box 23 . THEN RETURN ALL COPIES TO THE URBAN CORPS. TO AGENCY COORDINATOR: l. The intern who brings this form hos been assigned to the specific position whose Ass ignment number appears in Box 10 . 2. If you accept the intern for the assigned position, complete Boxes through ]l. 3. Retain the PINK copy for your records. 4. RETURN THE REMAINING FOUR COPIES TO THE INTERN . 5. If th e intern is not acceptable or decl ines the pos ition, check the appropr iat e space in Box 13 and _return al I five copies of the form to the intern. !,1 NOTE : If there ore any questions regarding placement procedure, please feel free to coll the URBAN CORPS at 524-8091 or write: ATLANTA URBAN CORPS 30 Courtland Street, N. E. Atlan t a , Georgia 30303 �
