San Diego Community College District
Cooperative Work Experience Education
Program Application
CRN
Course # 272
270
Campus City
Mesa Miramar
# Units
STUDENT INFORMATION
Last Name
First
Student ID
M
F
Address
City
Zip
Home Phone Cell Phone
e-mail
Declared Major
Occupational Goal
Educational Goal Certificate AA/AS
Transfer
Total work experience units completed
EMPLOYMENT/ INTERNSHIP INFORMATION
Your job title
How long have you worked for this company?
How long in this position?
Is your position paid non-paid ? Can you be reached at work? yes no Phone
Rotating/varying schedule? Yes No
Total hours work per week
Work Schedule:
Sun Mon Tues Wed Thurs Fri Sat
Enter shift hours
Include a.m. / p.m.
COMPANY INFORMATION
Company Name
Address
City
Zip
Work/Internship site address (if not same as company address)
City
Zip
Supervisor/ Mentor
Title
Phone
e-mail address
Cell Number
Fax
Special worksite access requirements (such as base pass, private security, parking permit / parking availability):
Please specify any days / hours that are not good for scheduling worksite visits between you and your supervisor (including travel, conference dates, vacations, etc.)
STUDENT AUTHORIZATION
Non-Discrimination Policy: It is the policy of San Diego Community College District to provide all persons with equal employment and educational opportunities
regardless of race, color, sex, religion, national origin disability, marital, or Vietnam-era veteran status.
As a Work Experience student, I understand my instructor / coordinator will be providing information about my work experience educational activities and enrollment
to my employer/mentor and my employer/mentor will be providing information to my instructor / coordinator concerning my educational job-related objectives.
Student Signature _______________________________________________________________________________
Date _________________________________
FOR OFFICE USE
Conference dates: (1) (2)
Student consultation notes_________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Dropped / Withdrew
Date / /
Course Completed
Total Hours
Final Grade
Comments
Instructor / Coordinator Signature ______________________________________________________________
Date __________________________________
Semester
Fall
Spring
Summer
Year
VA Benefits
Financial Aid
International Student
Over 18 yrs of age
yes no
Sign & Date in person with Instructor
