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Student Application Form
Complete this form and return it to the Cooperative
Education and Internship Office, Montgomery College,
Takoma Park Campus, Takoma Park, MD 20912.
Or you may fax the form to our office at the above number.

Semester you want to CO-OP: Date:
Last Name:
First Name: Date of Birth:
Address: Phone(Home):
City: State: Zip: Phone(Work):
e-mail: Fax:
Are you a U.S citizen? Yes No

If no, what is your visa status?

 

 When does it expire?
If not a U.S citizen do you have a work permit? Yes No

When does it expires?

Campus: Major:
G.P.A in Major: Cumulative G.P.A: Credits completed in Major:
Career Field:
Courses completed in major:

 
Are you seeking an Associate's Degree or a Certificate? Degree Certificate
Credits completed toward degree or certificate: Expected graduation month & year:
Type of co-op job would you prefer:
What skills do you have for this position?

 
What type of transportation do you have to get to a job? Car, Bus, Metro.

 
When are you available to work, Mornings, Afternoons, Evenings, Part-time, Full-time, Weekends?

 
Would you be willing to take an unpaid job if a paid job cannot be found?
Are you currently employed in a job related to your major? Yes No
Do you want to keep the job you have now (if in your major) and use it as your Co-op job?
Are you currently employed? Where?
Supervisor: Phone#:

Student Agreement
Student's Name:
MC Student ID:

I authorize the Cooperative Education & Internships Office to release to prospective employers information relating to my academic transcripts and Cooperative Education/Internship records, when, in the judgement of the professional development and/or assist in my effective placement.

I agree, that if accepted into the Cooperative Education & Internships Program, I will complete the course requirements the best of my ability.

Once having accepted a position and while under a current Learning Agreement, I will not seek out or accept another Cooperative Education assignment from any other employer.

Upon accepting a Cooperative Education/Internship assignment, I recognize my responsibility to complete course requirements of the Cooperative Education /Internships Program to the best of my ability, to meet all the standards, tasks and conditions of my employment, and to abide by the work schedule established by my employer.

I understand that accepting a position to which I have been referred by the Cooperative Education & Internships Office obligates me to register and pay for the three (3) credit Cooperative Education course CE260.  If employed by the Federal government, I must also register for CE261.

I have read the above information and understand my responsibilities herein.

Signature: Date:

  

 

Phone: (240) 567-1360;  Fax: (240) 567-1327