Host Interest Form

Host Organization

Contact Person

Street Address

City, State, Zip

Your Email

Website

Proposed Training Tasks

Desired Skills

Area of Study/ Major

Start Date

Preferred Duration of Training

Stipend

Do you have an Employer ID number?
YesDon't knowNo

Do you have a Workman's Compensation Insurance?
YesDon't knowNo

Do you have more than 25 employees or more than $3M in annual revenue?
YesDon't knowNo

Are you a member of a Regional SACC Chamber?
YesDon't knowNo

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