Junior Achievement Form

Company _______________________________
Brief Description
of Company		 _______________________________
Address _______________________________
_______________________________
Contact _______________________________
Title _______________________________
Phone _______________________________
Fax _______________________________
Email _______________________________

O Yes, I would like to be a part of Job Shadow Day.
        Please contact me as soon as possible to further discuss this project.

O Yes, the 8:30 AM until 1:00 PM time frame works for my company.

O No, February 2nd does not work for my company.

Total number of students our company can work with ________.

Please list the number of students your company can shadow by department.

# of students ____ Department _____________________________

# of students ____ Department _____________________________

# of students ____ Department _____________________________

# of students ____ Department _____________________________

O Yes, my company will provide lunch for the students visiting my company.

O No, I can't provide lunch, but encourage the participating students to bring their own lunch.

O I have a specific Middle/High School(s) that is of interest to my company:

        _______________________________
        (Name of preferred school)

Please note that in the event of inclement weather, and Schools are closed, an alternative date of February 9th has been scheduled.

Please fax completed form to Bob Brauer at 821-1700. Please call 821-2100 for more info.