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* 1. First name:

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* 2. Last name:

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* 3. Job title:

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* 4. Company:

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* 5. Industry:

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* 6. Briefly list your main responsibilities to help our students better understand what your job entails.

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* 7. Will the student be required to sign a confidentiality agreement in your company?

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* 8. Location of workplace (neighbourhood or city)?

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* 9. What month is most convenient for you to host a student this summer?

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* 10. Email:

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* 11. Telephone:

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