Summer _________
Date: Email:
Name:
Home Address:
Phone #1: (check one) Cell ____
Work ____
Phone #2: (check one) Cell ____
Paid _______ Unpaid _________
Reason for enrolling in Work Experience (check all that apply):
(list degree __________ )
FOR WORK EXPERIENCE COORDINATOR TO FILL OUT ONLY:
Number of Mission College Units Completed: ________
Number of Major Subject Units Completed: ________
Work Experience Courses Offered in Major: Yes __________ No __________
One _____ Two _____ Three _____ Four _____
(check one) General WE: ________
(select Occupational if student's job is in same field as student's major and if dept offers Occup WE; otherwise, select General)
Nearest cross street: _____________________
Degree rqmt: ___________ (list degree: ___________ ) Certificate Rqmt: ___________ (list cert: ___________ )
MC Units Earned to date: _________________
___________________________________ Date: _____ ___________________________________ Date: _____
Major: ________________________
Student ID: ______________________________
To stay qualified for financial aid: __________
Other reason (pls explain): ______________________________________________________________________
Do you want to receive a Pass/No Pass or a Grade?: ____________________
Your Job Title: _______________________________________
Job Duties: __________________________________________
Supervisor's Phone #: (____) _______________
______________________________________________
Cooperative Work Experience - Student Application (Sp12)
____________________________________
___________________________________________________
(____) _______________________
(____) _______________________
Employer/Company Name: ___________________________________
Supervisor's Name: __________________________________________
Work Address: ______________________________________________
Occupational WE: ________
Do you want to receive a Pass/No Pass or a Grade? ______________
Are you currently a Mission College student? __________
Elective for AA/AS degree: _________
To qualify for participation in a sports team: __________
__________________________________________________________________________________________________________
Is this paid work or unpaid work?
Please indicate your weekly schedule: (ex: Mon 8-2pm, Tues 9-3am, etc..)
Work Experience Coordinator
Work Experience Instructor
Sun: ________ Mon: ________ Tue: ________ Wed: ________ Thu: ________ Fri: ________ Sat: ________
Work Experience Units Eligible for
Recommended Course for Student:
(75 hours of paid work or 60 hours of unpaid work for each unit - work must occur between development of learning
objectives and end of semester conference)
Signatures (only one required)
