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Employment-Based Field Placement Application (BSW)

Department of Social Work (BSW Program)
Tricia Snyder, Field Coordinator
email: tsnyder@brockport.edu

  • Page 1 of 3 - Part I: Student

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  • PART I: Completed by the Student

  • Student Name: Student Name: *
  • Must be 9 digits.   Currently Entered: 3 digits.
  • Employer Address: Employer Address: *
  • Employment Start Date: Employment Start Date: * / /
    Pick a date.
  • List the department, supervisor name, job title, and employment dates for each program in which you have worked for the agency:

  • Program 1:

  • Program 2:

  • Program 3:

  • Please provide the following information (required for consideration of approval):

  • PART II IS TO BE COMPLETED BY THE AGENCY

    Agency Contact: Click on the "Continue" button below to proceed to Part II.

  • Students: Save your work!

    1. Check the box next to "Save my progress and resume later".

    2. Have you finished your section of this form?
            NO -- > Enter your email address.
            YES --> Enter your Agency Contact's email address -- NOT YOURS.

    3. Click on "Save form and resume later".

    4. An email will be sent to your Agency Contact with the subject, "Your attention requested: Field Placement Application".

    5. Follow up with the Agency contact to make sure they have received the "Your attention requested" email.

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