Friends Services Alliance


2023 FSA Internship Host Site Application
Your Name *
Job Title *
Organization *
Email *
Phone *
Designated Preceptor Name *
Designated Preceptor Email *
Designated Preceptor Phone Number *
Is the contact for logistics (travel information and other details about the internship) the same as the Preceptor? *	Yes No
If you answered no, please list the name of the contact for logistics.
Email of contact for logistics (if different from Preceptor)
Phone of contact for logistics (if different from Preceptor)
Please acknowledge. I have read and understand the Host Site Internship requirements (available on fsainfo.org) *	Yes No
Description of Internship Experience, including educational objectives and project goals. (You may also submit these as a Word document after submission of this form.)
Please describe the intern's living arrangements for the duration of the internship. *

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