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Project Xtern Facility Agreement

This form is to be used by facilities that wish to participate in Project Xtern and allow AAPC newly certified members to contact them about internship opportunities. Please do not complete this form for any other purpose.

Contact Information

Facility Name:
Facility Address:
Contact Name:
Contact Phone:
Contact Email:
Additional information (i.e. training from a particular school):

Referral Information

To whom may we thank for referring you to us:
Referral Name:
Referral Phone:
Referral Address:
How did you hear about us?	Local ChaptersWorkshopsWebsite Direct MailOther
	If other, please specify:

I agree to the Project Xtern terms and conditions.