Cooperative Education

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Student Application for Cooperative Education and Internships


First Name:
Middle Initial
Last Name:
Trojan "T" Number:
Address:
City:
State:
Zip Code:
Date of Birth:	format mm/dd/yyyy
Sex:	Male Female
Phone #:
Email:

Major Code:
Total Hours Completed:
Projected Graduation Date:
GPA:
Classification:
Are you receiving financial aid?
How did you hear about the program?
If other, please specify
When did you hear about the program?
If other, please specify
What type of Co-op / Internship employment do you prefer:
Which semesters would you be available for a Co-op / Internship?	Spring Summer Fall
Ethnicity: (please select)

Geographic areas desired (please list in order of preference):

All education experience after high school (example: transfer hours):

Special training/specific skills pertaining to your major:

Are you currently employed by UALR?
If yes, what department?
How many hours per week?
Are you currently employed by an "outside" employer?
If yes, who is your employer?
What is your employer's phone number?
How many hours per week?

Before submitting this application, please read the following:

I understand that my participation in the Cooperative Education Program indicates my acceptance of the written regulations of the program.

I hereby authorize the release of my records to employers.

These records, which may include this application, UALR transcripts, G P A employer application, and resumes, are to be used only for the purpose of evaluating my qualifications in the Cooperative Education Program.

When I accept employment through the Co-op Program it is expected that primary emphasis will be placed on academic success at UALR and commitment to the Co-op position. If I have other employment, I must receive approval from the Director of Cooperative Education for such employment.

UALR Office of Cooperative Education
Ross Hall 417
Little Rock, Arkansas 72204
501/569-3584
501/569-3588 (Fax)