Employer Information
Business Name ____________________________________________________ FEIN____________________________
Employer Address ____________________________________________________________________________________
City ______________________________________State _________________ ZIP______________________________
Employer Contact Name _______________________________________________________________________________
Employer Contact Phone ______________________ Email Address ______________________________________________
My name and signature below indicates that I agree to the terms of the Internship Grant Program contract.
Employer’s Name (printed) Signature Date
Select the industry area of the internship
Financial Services Health Care Retail, Hospitality & Tourism Construction & Utilities
Life Sciences Technology Transportation, Logistics & Distribution Advanced Manufacturing
Intern Information
Intern Name ________________________________Gender Male Female Phone ___________________________
Intern Address_______________________________________________________________________________________
City ______________________________________State __________________ ZIP______________________________
U.S. Citizen? Yes No Permanent? Yes No Date of Birth ______________________
Alien Registration # __________________________ Expiration Date_____________________________________________
Briefly describe interns job duties ________________________________________________________________________
Hourly wage to be paid to intern _________________ Number of hours per week ____________________________________
Approximate start date________________________ Approximate end date _______________________________________
Name of school ______________________________________________________Grade Level ______________________
Address of school ____________________________________________________________________________________
My name and signature below indicates that this student meets the eligibility criteria to participate in a paid internship program
established by the College or University I represent. By signing this form, I agree to act as the intermediary between the New Jersey
Department of Labor & Workforce Development and the participant employer.
College/University Official’s Name (printed) Signature Date
Position Held at College/University Email
WD-159 (9/17)
Internship Incentive Program Application
for College & University Students
ALL FIELDS above must be filled in completely and accurately
prior to the application being considered.
Email application to:
The employer agrees:
1. To provide training and supervision to student in order that the student may attain work experience
within New Jersey’s eight key industries. The LWD will provide to the employer 50 percent of the
student’s salary during the Internship period on a cost reimbursement basis. LWD will match employer’s
contributions up to $1,500. These match funds cannot be used to satisfy a cost-sharing or matching
requirement of another program. Holiday, sick, vacation and overtime are not reimbursable under this
2. To employ under this agreement only student interns enrolled in a New Jersey high school, college or
university who have been certied by the NJ Department of Labor & Workforce Development (LWD) as
eligible for program services.
3. To ensure that no currently employed worker is displaced by any student in the Internship Program;
no student may be employed under this program if any other individual is on layoff from the same or
equivalent job or when the employer has terminated any regular employee without cause or otherwise
reduced its workforce with the intention of lling the vacancy so created by hiring a student whose wages
are subsidized by this program; and no student may be employed that is directly related to a supervisor or
the employer.
4. To electronically acknowledge the contract application and supporting payroll documentation to the
LWD for the 50 percent reimbursement of the student’s wages. To cooperate with the LWD in evaluating
the progress of the student participant, and in such cases where termination is determined by the
employer to be warranted, to contact the LWD before termination.
5. That this contract is being entered into with the expectation and understanding that upon completion
of the graduation, the employer will consider employment of student intern. That if, for any reason, the
student would not be considered for employment the employer may be required to submit to the LWD
6. That nothing herein alters the nature of the employment relationship (at-will or other) between the
student and the employer. However, if it is determined by the LWD that the employer has breached
any of the provisions of this agreement, the LWD may refuse payment of any invoice(s) and may seek
reimbursement of funds paid to the employer by the LWD under this contract.
7. To be in compliance with all federal and State laws and regulations, including but not limited to,
the minimum wage rate of $8.44 per hour, the requirement that the employer provide workers’
compensation protection for the student participant and the requirement that the employer not
discriminate against any person who is employed in the work covered by this contract or against any
applicant for such employment because of race, creed, color, national origin, ancestry, age, marital
status, affectional or sexual orientation, familial status, disability, nationality, sex, gender identity or
expression or source of lawful income used for rental or mortgage payments, subject only to conditions
and limitations applicable alike to all persons.
By electronically acknowledging the Internship contract application and submission of payroll documentation
for an Internship Grant program participant, the employer hereby covenants and agrees to the general
provisions outlined above and those stated in the program provisions document.