Business Interest Form Intermediary Network Business Interest Form Intermediary Network Business Interest Form Business/Industry/Organization Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Business/Industry/Organization Brief DescriptionContact Name #1 First Last Title PhoneContact Name #2 First Last Title PhoneMiddle School Partnership Opportunities (6th - 8th grades)Please select at least one that interests you. Career Classroom Speaker Workplace Exploratory Interactive Career Event Teacher/Administrator Professional Development High School Partnership Opportunities (9th - 12th grades)Please select at least one that interests you. Career Classroom Speaker Workplace Exploratory Interactive Career Event Job Shadows Internships/Apprenticeships Summer Teacher Externships Informational/Mock Interviews Teacher/Administrator Professional Development Check boxes, or complete information, detailing what your business is willing to host: Student Job Shadow: Individual student or a small group of students observe worksite; typically 2-4 hours during the day Workplace Exploratory: Small or large group tours provide students an opportunity to interact with professionals and learn about various positions at a worksite; typically one hour Student Other Experience: Students participate in work-based learning activities not conducted at a worksite; career day, career fair, classroom speaker, STEM events, etc. Educator Externships: Expand educator's business and industry knowledge by spending time at a work site directly related to their discipline. Educators obtain knowledge and experience they can take back to the classroom and align and incorporate into their curriculum; 40 hours Student Internship: Hands-on work experience at work site for students in grades 11 and 12; 45-90 hours Student Internship InformationIf you have marked yes to offer a student internship please provide more details here. (Hours per week, paid or unpaid, etc.)Careers Represented/PromotedPlease select at least one career area. Agriculture, Food & Natural Resources Architecture & Construction Arts/A/V Technology & Communications Business Management & Administration Education & Training Finance Government & Public Administration Health Science Hospitality & Tourism Human Services Information Technology Law, Public Safety, Correction & Security Manufacturing Marketing Science Engineering & Mathematics Transportation, Distribution & Logistics Other Date MM slash DD slash YYYY Site RestrictionsPlease list any restrictions that your company may have (age limits, dress code, etc.)I would like to schedule a meeting with an Iowa Valley Intermediary representative to learn more about the program. Yes No I'm not interested in working with Iowa Valley Intermediary program. Please check the box to be removed from the mailing list. PhoneThis field is for validation purposes and should be left unchanged.