Personal Data

Name:

Student ID / Birthday:

Are you currently enrolled in COOP:

Yes
No

Street:

City:

State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Main Phone:

Alternate Phone (Not required):

Email:

Employer Data

If interning, list place of Internship.

Employer:

Street Address:

City:

State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Work Station Phone:

Supervisor Phone:

Supervisor:

Job Title:

Hourly Wage:

Enrollment Data

CRSE and CRN are located on your Student Schedule / Bill

Semester: Fall 2013 Summer 2013 Spring 2013

Major: Select Major Administration of Justice Agriculture Allied Health Art Auto Collision Repair Auto Technology Behavioral Science Biology Business Business Education Chemistry Dance Early Childhood Education Economics Education/Paraprofessional Engineering Tech/Pre-Engineering English Fire Science Foreign Language Health History Hospitality Management Humanities Integrated Mfg Tech Info Tech (Computer) Literature Mathematics Mass Communications Music Philosophy Physical Education Physical Science Physics Political Science Religion Social Science Speech Surveying Theatre Welding
 

CRSE:
(Ex: CP193, BE193-2, CP197, BA197-6)

CRN:
(Ex: 10170, 5706)

Credit Hours Select Credit Hours 2 Credit Hours 3 Credit Hours 4 Credit Hours 5 Credit Hours 6 Credit Hours

How did you hear about COOP and Interships:

The Co-op Office

Mailing

Another University / College

Butler Advisor

Friend / Family

Co-op / Intern Coordinator

Brochures

Co-Worker

Other

I give permission to update my college records with this information