Co-op Assignment Information Survey

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1. First Name:

First Name:

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2. Last Name:

Last Name:

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3. Last four digits of your student ID:

Last four digits of your student ID:

*
4. Cooperative Education Period:

	Month	Year
Start Date	Cooperative Education Period: Start Date Month	Year
End Date	End Date Month	Year

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5. Job Title:

Job Title:

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6. Manager's Name:

Manager's Name:

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7. Manager's Phone:

Manager's Phone:

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8. Manager's Email Address:

Manager's Email Address:

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9. Company Name:

Company Name:

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10. Company Address:

Company Address:

11. Address of co-op employment if different than Company's Address:

Address of co-op employment if different than Company's Address:

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12. Gross Salary: (hourly rate before taxes)

Gross Salary: (hourly rate before taxes)

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13. Hours per week:

Hours per week:

14. Comments: (in most situations this is left blank)

Comments: (in most situations this is left blank)

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15. Address where you can be contacted during the co-op period:

Address where you can be contacted during the co-op period:

Co-op Assignment Information

*1. First Name:

*2. Last Name:

*3. Last four digits of your student ID:

*4. Cooperative Education Period:

*5. Job Title:

*6. Manager's Name:

*7. Manager's Phone:

*8. Manager's Email Address:

*9. Company Name:

*10. Company Address: