What days and hours can you work?
CITIZENSHIP
REQUIRED
PLACEMENT INFORMATION
DEMOGRAPHIC INFORMATION: OPTIONAL
This information will be kept confidential and will be used only for reporting purposes.
Cooperative Education
Student Application
STUDENT INFORMATION
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: rhenderson@manchestercc.edu Phone: 860-512-3312 Fax: 860-512-3371
Street Address
City State Zip
Home Phone Number Cell Phone Number
Student’s Signature Date
Personal Email
June 2017/PR
www.manchestercc.edu/coop
Fall of 20
Spring of 20
Summer of 20
Part-time
Full-time
Either
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.)
Yes
No
Gender
Male
Female
Ethnicity/Race (Select one or more)
White
Hispanic/Latino
Black or African American
Asian
American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander
MCC Banner ID Number
Number of Credits Earned GPA Major
Semester preference:
Desired work schedule
Please select only one designation.
American
Naturalized
Applied for Citizenship
Permanent Resident
Student Visa
Not on Student Visa — Other
Geographic preference Type of position preferred
Special area of interest Are you using your current employer for co-op?
Yes
No
Do you prefer a paid or unpaid placement?
Paid
Unpaid
When are you able to start?
Do you have transportation restrictions?
Yes
No
Desired position
Temporary
Long term
Either
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?
Yes
No
Would you work 2nd or 3rd shift?
Yes
No
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?
Explain.
