PSU Standard Student Affiliation Agreement Request Form

Submitter Name

Type of Affiliation Agreement

Month and Year Agreement is Needed

e.g., 01/2026

Facility Information

Corporate/Contract Company

(if applicable)

Facility Name

Facility Address

Facility Address 2

Facility City/Town

Facility State/Province

Facility ZIP/Postal Code

Facility Country

Facility Contact

Facility Contact Email

Facility Contact Phone Number

PSU Contact Requesting Agreement Section

PSU Contact Requesting Agreement

Requester's Penn State Email Address

Requester's Penn State Campus

Requester's Penn State Title/Position

Please indicate whether this request is for a specific campus and academic program or for all Commonwealth Campuses and programs

(If specific, please list the campus and program name.)

If you are a current Penn State student requesting an affiliation agreement, please provide the following:

Your Academic Program

Your Penn State Internship Advisor’s Name

Your Penn State Internship Advisor’s Email Address

Other Comments