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* 1. Please provide details of the Company or Institution and a point of contact:

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* 2. Where would the intern / placement student be located (city/town/county)?

Please list as many locations as applicable:

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* 3. Would you be willing / interested to offer a one week placement to a 6th form student through the Social Mobility Foundation?

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* 4. Would you be willing / interested to offer a short term internship / placement (usually up to a few weeks) to an undergraduate student through University Geoscience UK?

T