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* 1. Business Name

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* 2. EIN #

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* 3. Youth Career Services has permission to use your worksite's Federal EIN # for work permit purposes?

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* 4. Work Site Address

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* 5. Business Address (if different from above)

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* 6.  Primary Contact Name:

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* 7. Primary Phone Number:

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* 8. Primary Cell Phone Number:

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* 9. Primary Email address

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* 10. Secondary Contact Name:

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* 11. Secondary Phone Number:

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* 12. Secondary Cell Phone Number:

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* 13. Secondary Email Address:

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* 14. Number of Interns to mentor at this work site:

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* 15. ADP Timesheet Phone Number (This company landline phone number will be used by the Interns to sign-in and sign-out via an automatic system.)  *** Enter numbers only. 

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* 16. Please select the answer(s) that best apply to your work site. 
*** We will be intentional in assigning requested Interns to your work site. However, situations may arise that will prevent the assignment of your requested Intern. If this occurs, we will share this information with you before replacement Interns are assigned.

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* 17. Is there a bus stop within reasonable walking distance of this facility (1/4 mile)?

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* 18. If no, please estimate the distance to your facility.

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* 19. Which of the following Industry Sectors best describes your company?

 
 25% of survey complete.

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