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WORK-BASED LEARNING APPLICATION
Last Name: First Name: Middle Initial:
PO Box/Street:
City: State: Zip:
Home Phone: Cell: Work:
Student ID Number: Date of Birth:
Curriculum Major: Advisor:
Grade Point Average: Email:
Projected Graduation Date:
I am presently employed in a job that is closely related to my curriculum.
Employer:
Address:
Work Schedule: (Days) (Hours)
Immediate Supervisor: Phone:
I am presently employed or unemployed in a job that is not related to my
curriculum, and I am willing to be placed in a career related position.
(If you would like to provide a resume, please include it with your application. Every
effort will be made to assist in finding placement in a career related work experience, but
placement is not guaranteed. You, as the student for this class, are the primary person
responsible for locating employment which must be approved by your WBL instructor.
The WBL office and faculty in your major do try to assist where possible.)
In rare circumstances, employment through Work-Based Learning may affect the
amount of financial assistance students receive from other sources. It is each
student’s responsibility to check with their Financial Aid resources.
Applicant’s Signature: Date:
TO BE COMPLETED BY ADVISOR: For state auditing purposes, please verify the following
eligibility information for the above student to participate in the Work-Based Learning
Program in the upcoming semester.
Total Major Elective Hours Available: Cumulative GPA: (min 2.0)
WBL Program Prerequisites Met: (List)
Work Site: Supervisor:
Address: Phone:
Work Site Confirmed: Yes ( ) No ( ) Date of Confirmation:
Eligible for WBL: Yes ( ) No ( ) Recommended for WBL: Yes ( ) No ( )
Advisor’s Initials: Date:
TO BE COMPLETED BY PROGRAM HEAD: Instructor Assigned:
Program Head’s Signature: Date:
OFFICE USE ONLY: Date Application Received:
