UPDATE: As of Dec. 5, 2022 MTIP is no longer accepting new intern verification requests for spring 2022 due to reaching funding capacity for that semester. Intern verification requests are being accepted to support summer 2023 and beyond for intern recruitment efforts.

Employer's MTIP application number*:
(Provided to your employer when they applied for funding.)

Your name*:
First:
Last:

Personal email address *:
If you are not a UMBC student, please do not provide your college "edu" email. Please provide a gmail, yahoo, hotmail, comcast, me.com, etc. email so as not to conflict with any existing or future Handshake account at your current college.

LinkedIn Profile URL:

Cell/Primary phone number*:

Permanent Address 1*:

Address 2:

City*:

State:*:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code*:

Race:
-select one- American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteOther

Gender:
-select one- Male Female Other

The following describes me (select one that applies to you)*:

	Current college student attending a Maryland higher education institution.
	Maryland high school graduate attending a higher education institution outside of Maryland.
	Graduate (within 12 months) of a Maryland higher education institution.
	Maryland resident, with a 2 or 4-year degree, who has been honorably discharged from the U.S. Armed Forces, The National Guard or a Reserve component of the Armed Forces within the last 18 months.
	The above categories do not apply to me.

Current/Recent University/College*:

Major(s)*:

Class level*:
-select one- Freshmen Sophomore Junior Senior Grad Student Alum

Graduation Date*:

Month	Year (YYYY)
January February March April May June July August September October November December

Cumulative Grade Point Average*:

Action:
In addition to submitting this form, please send your unofficial transcript verifying your GPA to mtip@umbc.edu (PDF attachment preferred).

Organization/company name*:

Internship Title*:

Semester/Term you are to be funded by MTIP*: -select one- Fall Spring Summer   Year*: -select one- 2023 2024

Hourly Pay Rate*: $/hour

Estimated Hours Per Week*:

Intern Supervisor:
First name*:
Last name*:
Title:
Department:
Primary work phone number*:
Email address*:

Is this your first or second semester with MTIP?* -select one- First Second

How did you find your internship?* -select one- MTIP website Your College's Job Listing Website Baltimore Collegetown Website Other Website such as Indeed or LinkedIn Career Fair/Recruitment Event Support from your College Career Center Network: Family, Friend, Faculty Referral Other

Verification Confirmation*
I certify that the above information is correct and will be used to verify my internship employment as a requirement for Maryland Technology Internship Program funding to your employer.
Yes