Employer Name

Co-op Start Date (mm/dd/yyyy)

Your Personal Information:

Student Name Student ID

Major Accounting Adult Learning & Development Anthropology Applied Biomedical Engineering Applied Communication and Methods Art Biology Business Administration Business Economics Chemical Engineering Chemistry Chemical Engineering Classical & Medieval Studies Communication Communication Management Community Agency Counseling Computer & Information Science Computer Engineering Computer Science Criminal Justice-Minor Criminology Culture Communication & Health Curriculum and Instruction Dramatic Arts Early Childhood Education Economics Education Electrical Engineering Electronic Technology Elementary Education Engineering Mechanics English Environmental Engineering Environmental Policy Environmental Science Environmental Studies Ergonomics Human Factors Film & Digital Media Finance French Geological Sciences German Health Care Administration Health Sciences Historic Preservation History Human Services Industrial Engineering Information Systems International Business International Relations Journalism & Promotional Communication Juris Doctor Labor Relations & Human Resources Liberal Studies Linguistics MAFIS Management & Labor Relations Marketing Mathematics Mechanical Engineering Mechanical Technology Medical Technology Middle Childhood Education Music Nonprofit Administration and Leadership Nursing Occupational Therapy Operations Management & Business Statistics Paralegal Studies Personally Designed Major Philosophy Physical Education Physical Therapy Physics Political Science Psychology Public Administration Public Health Public Safety Management Regulatory Biology Religious Studies Social Science Social Studies Social Work Sociology Sociology/Criminology Software Engineering Spanish Special Education Speech & Hearing Speech Pathology & Audiology Sports Management TESOL Total Quality Management Urban Economic Development Urban Planning Design & Development Urban Services Administration Urban Studies Urban Studies & Public Affairs Women's Studies

GPA Status in Major Sophomore Junior Senior Graduate Student

Career Coordinator Anita Young Elizabeth Okwudi Grace Scales Jim Tomsic John Scanlan Julie Capuano Karen Lieske Kathi Howard Primes Linda Pfaff Matiera Shaw Nancy Edwards-Grady Paul Klein Philomena Johnson Sharon Moss Yolanda Burt

Co-op Semester/Session Fall Spring Summer Year

Your Co-op Supervisor's Name

Your Co-op Supervisor's Phone Co-op Supervisor's Email

Your Hourly Rate of Pay: Number of hours you work per week:

Number of Previous Co-ops with same employer: Number of Previous Co-ops:

Career Services Course(s) Taken CSC 121 CSC 224 CSC 321 CSC 300 CSC 400 ESC300 490/690

Have you completed a Co-op application? Yes No

Have you reviewed your Co-op Learning Agreement (for CSC 300 or 400) or Learning Objectives with your Faculty Mentor (for ESC 300, or other 490/690 course)? Yes No