Public Service Corps

City Agency Intern Request Form

* Indicates required fields

Agency and Work

Agency*

Agency Code

Name of Center

Name of Work Unit*

Work Location Address*

City*

State*

ZIP Code*

Borough*

Agency PSC Coordinator Name*

Agency PSC Coordinator Phone*

Agency PSC Coordinator Email*

Work Unit Function and Supervisors

Function of Unit*

Work Unit Head*

Phone*

Fax

Email*

Supervisor*

Supervisor Phone*

Supervisor Fax

Supervisor Email*

Internship Description, Duties, Responsibilities and Prerequisites

Description of Internship*

Indicate the amount of work time spent on Non-Clerical, Clerical, or In the Field tasks in percentages.

Non-Clerical*

Clerical*

In the Field*

Special Experience Required to Complete Assignment

Skills Required

Courses Required (Preferred)

What skills can the intern expect to develop?

Interpersonal

Interviewing

Writing

Computer

Organizational

Analytical

Oral

Internship Schedule

Select a Program Year from the drop-down list below
Select an Academic Term from the second drop-down list below

Program Year*

Academic Term*

Interview Preference

Intern can go directly to Unit Head/Supervisor for interview

Intern must see Agency Coordinator first

Intern must see Agency Coordinator after seeing Supervisor

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