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Name

School

Birthdate

Telephone

Area of Interest/Type of Internship/Industry/Company

Career Academy program

I am interested in:

Internship

Job Shadow at a Company

Interview or Talk with a Business Person

Professional Business Mentor

Part-time or Summer Employment

Other

Other opportunities interested in:

Have you ever been employed?

Yes

Have you ever been employed?

Yes

I am a university/college/community college student?

If in university/college/community college, my major/area of interest is:

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