ࡱ> _a^%` lBbjbj |V̟̟6 &&&&&&&zf, #hhhhCF<"""""""$#%h'#E&N CCN N #&&hh]#z"z"z"N .&h&h"z"N "z"z"&&z"h 4| "z""s#0#z"-( -(z"-(&z"xe^z"GLeee##p" eee#N N N N $  :$^v&&&&&& Technology Internship Grant Application Form July 1, 2008 June 30, 2009 Instructions: Complete all sections of this form and return it electronically to  HYPERLINK "mailto:state-federal-grants@ksbor.org" state-federal-grants@ksbor.org Patricia Altwegg, Ph.D. Associate Director of Career and Technical Education Workforce Education and Program Accountability Kansas Board of Regents 1000 SW Jackson, Suite 520 Topeka, KS 66612-1368 Telephone: (785) 296-0620  HYPERLINK "mailto:paltwegg@ksbor.org" paltwegg@ksbor.org Applicant s Name (First, Middle, Last)  FORMTEXT       Years of Experience in Your Profession  FORMTEXT     Academic Degrees  FORMTEXT       Professional Credentials  FORMTEXT       Full time faculty  FORMCHECKBOX  Business/Industry Employee  FORMCHECKBOX  Previous Technology Internship:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Year(s) Internship Completed  FORMTEXT       Work Address Institution Name  FORMTEXT       Department  FORMTEXT        FORMTEXT  Street Address  FORMTEXT       FORMTEXT  City  FORMTEXT       State  FORMTEXT    Zip  FORMTEXT       Phone ( FORMTEXT    )  FORMTEXT       E-mail  FORMTEXT       Fax ( FORMTEXT    )  FORMTEXT       Memberships in Professional Organizations  FORMTEXT       Home Address Street Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT    Zip  FORMTEXT       Daytime Phone ( FORMTEXT    )  FORMTEXT       Evening Phone ( FORMTEXT    )  FORMTEXT       E-mail address  FORMTEXT       Technology Internship Grant Application Form INTERNSHIP SITE  FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT       Name of Co,-89HIK K T Ⱥwk\QJFJha h|hahuhamHsHhuhaCJaJmHsHhuhc5mHsHhuha5mHsHhh&>0J5mHsH&jhh&>5UmHsHh&>h&>5mHsHh&>5mHsHjh&>5UmHsH ha5h|ha5h&>OJQJhaOJQJh`ha5:CJ(aJ(h`ha:CJ(aJ(-JK A p $ & ( \ ^   !gda &gda &gdagda$a$gda $`a$gdGxlB " & ( t v x  »wocULhm>*OJQJjhm>*OJQJUhaCJOJQJaJh\ha>*jhu>*OJQJU&jh[F9heU>*OJQJUh[F9>*OJQJjh[F9>*OJQJUh\haOJQJ hk=hahaCJOJQJaJhaCJaJh|ha0Jjh|haU h|hajh|haU      2 4 6 J L N X Z \ ^ wk]T@]&jLhtVheU>*OJQJUhtV>*OJQJjhtV>*OJQJUhaCJOJQJaJh\ha>*jhGx>*OJQJU&jh\ha>*OJQJUha>*OJQJjha>*OJQJUhaOJQJ hk=haha%jhm>*OJQJUmHnHujhm>*OJQJU&j^hmh&xX>*OJQJU 8 : V X Z \ ^ p . 0 2 F ˸˭˩ϩϡϡϩπrihm>*OJQJjhm>*OJQJUh= 9haOJQJj haUjhaUjhaUhaj8hGxUjhGxUjhGxUhGx hk=hahk=ha>*jhtV>*OJQJU%jhtV>*OJQJUmHnHu" ^ X Z v .t~ &gda gd Q &@gdu  &gd Q <gdu &gda &@gdugda gda p&gdm pX D%gdaF H J T V X Z v  ÿp]YE]&jh[F9heU>*OJQJUhu%jh[F9>*OJQJUmHnHu&jh[F9heU>*OJQJUh[F9>*OJQJjh[F9>*OJQJUhuOJQJ hk=haha5CJOJQJaJhk=ha5hahk=ha>*%jhm>*OJQJUmHnHujhm>*OJQJU&jhmh&xX>*OJQJU  &(,.JLNbdfprtܭnbNnEha>*OJQJ&jh,' ha>*OJQJUh,' ha>*OJQJ jh,' ha>*OJQJUjhGx>*OJQJU&jphmhm>*OJQJUhmhm>*OJQJ jhmhm>*OJQJUh ha>*OJQJ#jhhaOJQJUhaOJQJjhaOJQJUhah QOJQJh Q˷שס𝏆r_QHhc>*OJQJjhc>*OJQJU%jhm>*OJQJUmHnHu&jhmh&xX>*OJQJUhm>*OJQJjhm>*OJQJUhah QOJQJjhGx>*OJQJU&j^huhm>*OJQJUhuhu>*OJQJ jhuhu>*OJQJUhuOJQJ hk=hah|ha>*"$&(2468LNPVXZ\^rtvrd[Gd&j, hmh&xX>*OJQJUhm>*OJQJjhm>*OJQJU+jh2hm>*OJQJUmHnHu&j h2h&xX>*OJQJUh2hm>*OJQJ jh2hm>*OJQJU hk=h Qh Q h Qh Q%jhc>*OJQJUmHnHujhc>*OJQJU&jL hchc>*OJQJUvʾungcgRFh2hm>*OJQJ jh2hm>*OJQJUhu hk=hu h Qh Q%jhm>*OJQJUmHnHu&j hmhm>*OJQJUhm>*OJQJjhm>*OJQJUh Q hk=h Qhha>*OJQJ hk=hahah Q>*OJQJjhm>*OJQJU%jhm>*OJQJUmHnHu  ptv۾|sng_UP@Uj hmhm>*U hm>*jhm>*UhaOJQJ hk=ha h Q>*h Q>*OJQJ%jhm>*OJQJUmHnHu&jv hmh&xX>*OJQJUhm>*OJQJjhm>*OJQJUhu hk=hu+jh2hm>*OJQJUmHnHu jh2hm>*OJQJU&j h2h&xX>*OJQJU&(*46:FüthTttLhaOJQJ&j hmhm>*OJQJUhmhm>*OJQJ jhmhm>*OJQJUhGx&jX hGxhGx>*OJQJUhGx>*OJQJjhGx>*OJQJUhmOJQJ hk=hah Qha hahahk=ha5hh Q>* h Q>* ha>*jhm>*UjhGx>*Ut|~$&FHJh:  !gdjM  !&gdjM &gdjMgdjM $ &a$gdjM gdGxgdaFH\^`dfprｯxq`T@`&j4h2h&xX>*OJQJUh2hm>*OJQJ jh2hm>*OJQJU hk=ha haha%jhm>*OJQJUmHnHu&j hmh&xX>*OJQJUhm>*OJQJjhm>*OJQJUhajhGx>*OJQJU&jH hQ"Pha>*OJQJUhQ"Pha>*OJQJ jhQ"Pha>*OJQJU.0DFHNPRTVjlnxzͿ|hdP&jhmh&xX>*OJQJUh Q&j h2h&xX>*OJQJUh2hm>*OJQJ haha%jhm>*OJQJUmHnHu&jhmh&xX>*OJQJUhm>*OJQJjhm>*OJQJUha hk=ha jh2hm>*OJQJU+jh2hm>*OJQJUmHnHuz~"&:DFJL`b͹֦qj_W_P<&jxhmh&xX>*OJQJU h|hjMhjMOJQJh|hjMOJQJ h7FhjMh7FhjM5:CJ(aJ(h7FhjM:CJ(aJ(hjM:CJ(aJ(hIK:CJ(aJ(hjM>*OJQJ%jhm>*OJQJUmHnHu&jhmh&xX>*OJQJUhm>*OJQJjhm>*OJQJUhhaOJQJ hk=haha>*OJQJbdnptv: :,:r::::::ҾҪҖیۅۅ}ofhjM>*OJQJjhjM>*OJQJUhjMCJaJ h|hjMUh|hjM>*&jhmh&xX>*OJQJU&jfhmh&xX>*OJQJU&jhmh&xX>*OJQJUhm>*OJQJhjM%jhm>*OJQJUmHnHujhm>*OJQJU#mpany Projected Dates No. of Weeks Hours Worked Length of Internship  FORMTEXT       ( FORMTEXT    )  FORMTEXT        FORMTEXT       Name of Employer Contact Telephone Job Title  FORMTEXT       FORMTEXT   FORMTEXT        FORMTEXT     FORMTEXT       Company Address City State Zip Code E-Mail  FORMTEXT       Fax ( FORMTEXT    )  FORMTEXT       1. Describe the importance of this internship to your current job assignment.  FORMTEXT       2. What are your expected outcomes of this internship?  FORMTEXT       3. Describe skill or knowledge you expect to gain as a result of this internship.  FORMTEXT       4. Please describe how your internship experience will impact (1) course competencies or outcomes and (2) student activities/projects/assignments.  FORMTEXT       5. How do you anticipate this internship will benefit (1) the students/industry employees, (2) the educational institution, and (3) community workforce needs? Please address each separately.  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