College of Southern Maryland - Cooperative Education Intake

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College of Southern Maryland
Cooperative Education Intake Form

* Required Field
* Conditionally Required Field

CSM Student ID: *	(please include leading zero ex: 0123456)
Last Name: *		First Name: *	MI:
Maiden Name:
Address:
City:		State:	Zip Code:

Home Phone (xxx-xxx-xxxx): *		Home E-mail:
Cell/Mobile Phone (xxx-xxx-xxxx):
Work Phone (xxx-xxx-xxxx):		Work E-mail:
Fax (xxx-xxx-xxxx):
Major:
Please select your desired learning goal:

It is the policy of the College of Southern Maryland and its Cooperative Employers to offer equal opportunity for participation in the Cooperative Education Program without regard to race, color, religion, national origin, age, or sex.
Are you currently employed in your major field of Study? *	Yes	No
If above answer is "yes", would you like to use your current employment as your co-op position? *	Yes	No
If the answer to both questions is yes, please be sure to complete the following employment information: *

Employer Company Name:	Supervisor's Name / Phone Number	/
Employer Address:	Supervisor's E-mail Address
Job Title:
City:	State:		Zip Code:

** NOTE: ITS students only. Please forward a summary of the project you plan to work on for this experience to jaynem@csmd.edu or fax to 301-934-7674. It must be an activity that is not already part of your current position. For more information on this topic, please view: http://www.csmd.edu/Academics/cooperative/infotech.html

** NOTE: Students seeking co-op in all majors except ITS, please submit a copy your of current position description to jaynem@csmd.edu or fax to 301-934-7674.

Note: Students not currently employed in field of study, please submit resume to jaynem@csmd.edu.

College of Southern MarylandCooperative Education Intake Form

College of Southern Maryland
Cooperative Education Intake Form