STUDENT INFORMATION:
First Name Last Name PID # E-mail
Present Address:
City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WV WI WY Zip
Phone Mobile
Student Address During Co-op (if known):
City State - AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WV WI WY Zip
Country Phone Mobile
Age Gender Select Male Female Ethnicity Select Black Hispanic White Other If other:
Technology Major Select A/E DESN ATE AVS CONS ECT M DESN MFG TE UIT VCT Academic Advisor
CO-OP EMPLOYER INFORMATION:
Employer Contact First Name Contact Last Name
Address City State - AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WV WI WY Other Zip Code
CountryPhone Fax Email Website
Job Title of co-op position Level applying for: Select TECH 289 TECH 389 TECH 489 Semester: Select SPRING SUMMER FALL Year: Select 2009 2010 2011 2012 2013 2014 2015
Job Description
Number of work weeks during co-op: Number of hours worked per week: Part-Time Full-Time*: Select PART-TIME FULL-TIME
Describe your weekly work schedule: (Ex.: M- F, 40 hours/week, 8:00 a.m.-5:00 p.m.)
Co-op Start Date Co-op End Date Hourly rate of pay ** $ Total wages earned during co-op $
* If Part-Time, prior approval from Co-op Office is required; Questions? coop@bgsu.edu ** If co-op is unpaid, you must submit a wage waiver form.
If pre-registered for classes, list classes to be dropped:
How did you secure the proposed co-op position? Select Place Pro/Co-op Office Military/ROTC Permanent Job Student Initiated Previous Co-op Position Other If other:
Previous Co-op History (as applicable):
Semester
Select SPRING SUMMER FALL
Year:
Select 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Supervisor
Univ Rep
Does the immediate supervisor have more expertise in your technology than you do? Select Yes No If no, explain:
Will you receive supervision on at least a daily basis? Select Yes No If no, explain:
Does your co-op employer understand you are to receive academic credit for your work? Select Yes No If no, explain:
How will your responsibilities increase in relationship to any previous co-op(s)?
Are you an associate degree holder? Select Yes No If yes, name of institution and year received:
Was any co-op completed via credit-by-examination (CBE) basis and/or still pending? Select Yes No If yes, which co-op level(s)?
By typing my name below, I acknowledge that I have completed the co-op workshop, obtained and understood the Cooperative Education Policy & Procedure Statement, posted my resume in my Place Pro account and understand the report requirements. I also understand and acknowledge all relevant deadlines, site visits, grading policy and fee structure.
Student Signature Signature Date
Print form before submitting
