2016-17 Public Service Scholar Program Agency Application
Organizations must complete this form and submit a job description by April 8, 2016 to be considered for a
2016-2017 placement. Please review the placement guidelines before submitting your job description.
Agency *
Department
Agency Address *
Type of organization *
Non-profit organization ☐
Government agency ☐
Legislator's office ☐
Other ☐
Brief agency description *
Placement Job description (attach as a separate document) *
Agency contribution toward student's stipend (voluntary) *
Contact person *
Contact job title *
Contact phone number *
Contact fax number
Contact e-mail address *
Supervisor (if other than contact)
Supervisor Job Title
Supervisor Phone
Supervisor Email