Registration form 2nd year internship

1a. General information

Name student: Student number: HvA-email: Telephone number student:
Dates of the internship: Coach:

1b. Contact details internship organization

Name of the organization:

Is the internship organization registered on Centuri?

YES

NO

(circle what is applicable)

The details below are only required if this organization is hosting an ISMB student for the first time. If the organization has hosted a student before, please continue with question 1c.

Visiting address:

Postal code: Country:

City:

Postal address:

Postal code: Country:

City:

Telephone number organization:

Website:

Registration form 2nd year internship

Page 1

1c. Contact details of the person who guides the student during the internship
Name contact person:

Reachable under these telephone number(s): Reachable under this SKYPE account:

On which days of the week is the contact person available?

E-mail contact person:

Postal address:

Postal code: Country:

City:

2.

Description of the organization

What is the core business of the organization?

3.

Description of the assignment

General description of the assignment

4.

Motivation of the student

Why is this a good organization to perform your internship at?

Please fill out the form and send it digitally to Karin Kuechler: k.kuechler@hva.nl
Registration form 2nd year internship Page 2