[Insert descriptive or explanatory text here.]
| Placement Name: * | |||
| Placement Address: * | |||
| Contact Name: * | |||
| Contact Phone: * | |||
| Contact E-mail Address: * | |||
| Supervising Attorney's Name: * | |||
| Supervising Attorney's Phone: * | |||
| Supervising Attorney's E-mail Address: * | |||
| Type of Organization: * |
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| Description of Placement: * | Briefly describe the assignment. | ||
| Type of Public Service Work to Be Performed (please check all that apply): * |
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| Areas of Law (please check all that apply): |
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| Number of Students Requested: | |||
| Course Prerequisites (if any): | |||
| Required Training (if any): | |||
| Availability: |
Weekends Evenings Weekday Mornings Weekday Afternoons |
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