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Mayor's Summer Youth Internship Program Worksite Proposal Application

2. Full Name of Worksite (ALL CAPS)*

   This is the name that will be sent out to the youth on their placement letters so please be accurate.

4. Category*
   -- Select One --AthleticsArtsDay CareSchool/EducationalMaintenance/Manual LaborMultiple (A combination of the list)/OtherOfficeOther Not Listed

   If you select "Multiple" or "Other" please give details in the next section

6. This section is only for those who selected "Multiple" or "Other" in the previous answer. Please explain below.

8. Name of Primary Supervisor*

   First Name, Last Name

9. Title of Primary Supervisor*

11. Phone Number for Primary Supervisor*

    Example (716) 123-4567

12. Fax Number (if applicable)

    Example (716) 123-4567

14. Email Address for Primary Supervisor*

    Example (fcarter@city-buffalo.com)

16. Name of Secondary Supervisor*

    First Name, Last Name

18. Phone Number for Secondary Supervisor*

    Example (716) 123-4567

20. Address - Number, Street, Suite (If Needed)*

    This is the address the youth are to report to on the first day of work. Example (65 Niagara Square - Room 1701)

22. City*

    Example (Buffalo)

23. State*
    -- Select One --NY

24. Zip Code*

    Example (14202)

26. Additional Details

    Use this box if there are additional specific details you would like the youth to have with their placement letter. Example (We are located on the 17th floor of City Hall)

28. Start Time on the 1st day of Summer Youth*

    This is the time that will be on the letter that is sent to the youth to let them know what time they will need to report to your location on the 1st day of work. Please be accurate and let the MSYIP office know immediately if this is to be changed

29. Number of youth requested for your site*

    The Mayor Summer Youth Internship Program does it's best to meet the increasingly growing request for youth at all sites. We are unable to guarantee that we will be able to fill all request but will try our best to assist everyone. Example (20) DO NOT ADD ANY ADDITIONAL DETAILS TO THIS, ONLY PLACE A NUMBER IN THE BOX

31. Other

    Use this box for all other comments your location would like to add with their Worksite Proposal.

33. By checking this box you hereby certify that all of the information given on this application is correct to the best of your knowledge*

    1. Yes, all information is accurate to the best of my knowledge
35. By checking this box you hereby certify that you have permission to register your program for the Mayor's Summer Youth Internship Program.*

    1. Yes, I am authorized to sign up my organization to be a worksite for the Mayor's Summer Youth Internship Program

37. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
39. Electronic Signature*

Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field