What days and hours can you work?
DEMOGRAPHIC INFORMATION: OPTIONAL
This information will be kept conﬁdential and will be used only for reporting purposes.
Last Name First Name MI
Please complete this form, sign, date and mail to:
Robert A. Henderson, Director of Cooperative Education, Manchester Community College, Great Path, MS #8, P.O. Box 1046, Manchester, CT 06045-1046
Email: firstname.lastname@example.org Phone: 860-512-3312 Fax: 860-512-3371
City State Zip
Home Phone Number Cell Phone Number
Student’s Signature Date
Fall of 20
Spring of 20
Summer of 20
Date of birth
Do you have a disability i.e.: physical, visual, hearing,
reading, perceptual, etc.? (Do not consider age, race or
sex in this category.)
Ethnicity/Race (Select one or more)
Black or African American
American Indian or Alaskan Native
Native Hawaiian or Other Paciﬁc Islander
MCC Banner ID Number
Number of Credits Earned GPA Major
Desired work schedule
Please select only one designation.
Applied for Citizenship
Not on Student Visa — Other
Geographic preference Type of position preferred
Special area of interest Are you using your current employer for co-op?
Do you prefer a paid or unpaid placement?
When are you able to start?
Do you have transportation restrictions?
Any other relevant issues or concerns?
Rate of pay expected
What types of jobs would you rule out?
How will you contribute to the process of ﬁnding a placement?
If paid positions are unavailable, will you consider an unpaid placement?
Would you work 2nd or 3rd shift?
Do you have any events planned, i.e. vacations that will interfere with your ability to complete 150-300 hours of work during the co-op period?