WEX12 Placement Request

Please complete the electronic form below.

Student Information

MM/DD/YYYY

New Info

If your address or phone number has recently changed, please provide updated info:

Program Info

Please answer ALL of the following questions:

 (If YES, please specify)

 (If YES, please specify)

What day(s) are best for you to attend a Work Experience placement (Please check ALL that apply)
7. Do you want to do your Work Experience during the following times? (Please check ALL that apply)