Career Services
Cooperative Education/Internship
Application and Consent
Personal Information
Name: _____________________________________________ Student ID Number: ____________________________
Address: ______________________________________ City: ____________________ State: _____ Zip: ___________
Phone: ____________________________ Email: _________________________________________________________
Major/Program: ____________________________________________ Crredit hours to date: _______ GPA: ________
Position(s) of Interest: ______________________________________________________________________________
What semester did you participate in the Introduction to Co-op (EBE 1000) class?
Fall Spring Summer Year _______
What semester do you plan to begin your co-op/internship class?
Fall Spring Summer Year _______
This is to certify that the undersigned agrees to allow Clark State to send certain personal information taken from his
or her ocial records at this college to prospective employers. The personal information released is to be forwarded
to the prospective employer through the Cooperative Education Program at Clark State.
The following items of information are hereby authorized to be sent to the prospective employer:
All academic records
Letters or Recommendation
Other (please specify) ____________________________________________________________________________
The purpose of the release of this information is to enable prospective employers to select students for Cooperative
Education/Internship assignments. It does not guarantee a co-op/internship position.
I understand it is my responsibility to stay in communication with Clark State’s Career Services. I also understand
that if I do not return calls and/or emails from the Career Services sta, I may be ineligible for future services
including job and internship assistance.
This authorization shall remain in eect throughout my participation in the Cooperative Education/Internship Program.
Student E-Signature: _____________________________________________________________ Date: ____________
NOTE: This release is obtained pursuant to the Family Education Rights and Privacy Act of 1977
Career Services
Clark State Community College
570 East Leel Lane
Springfield, OH 45505
Career Services
Melody Gast
Phone: 937.328.6468
Fax: 937.328.6133
Last updated: Friday, July 31, 2020.
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