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 Community Health Initiative (CHI)
Small Business Application for Student Internship

Incomplete Applications and those Businesses not meeting the Program Requirements will not be considered.

Requirements
  • A business in the health care or medical industry
  • Located in the Minnesota greater metropolitan area
  • In operation for at least three years
  • Able to provide on-going educational experience to students (For detailed program information and requirements, click here.).
Contact Information
Company Name
Contact Person
Title
Name of Business Owner(s)
(If more than one owner, please separate names with a comma.)
Address
City
State   
ZIP Code   
Phone   
Fax   
E-mail Address
Web Page   
Year Established   
Number of Employees:
 Full-Time   Part-Time
Legal Form of Ownership: Sole Proprietor Partnership Sub-chapter Incorporated
Business is
(Check all that apply.)

Minority-owned
Women-owned
Disabled-owned
Type of Industry:
Health Care Medical
Annual Revenue for past three years:

$ (2008)

$ (2007)

$ (2006)

What type of business is your company?
Manufacturing
Wholesale
Retail
Service
Construction
Please complete information below.
Business Description:
What are your core competencies?

Who is your target market and what geographical area(s) do they reside?
Please check the topical area(s) for which you are requesting technical assistance. DO NOT CHECK MORE THAN TWO CATEGORIES.

Public Health
Community Health Education
Social Work
Population Health Coordination
Nursing Care/Management
Health/Medical Research

Feasibility Study
Program Evaluation / Measurement
Other

If Other, please specify:

Describe your Community Internship in DETAIL. Please be SPECIFIC when describing the scope of this request. List the goals and objectives, tasks, timelines and proposed duties and responsibilities for the student intern. Describe how the results of this internship will benefit the community at large as well as the business. What valued experiences will the student gain by participating in this internship?

Please list any specific skills, knowledge or past experiences the student should have.
Please share any other information about your company or industry that would be useful in considering your application.

How did you hear about our program? (Check all that apply)

BCED Website
CHI E-mail Notice
 E-mail notice from another organization
(Please name.)

Organization Name:

Referral from another organization
(Please name.)

Organization Name:

Other

If Other, please specify:

Please PRINT a copy for your records before clicking the Submit button.
 
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Last modified on July 2, 2008