Internship
Cooperative or
Experiential Education
Application

for Jefferson Community & Technical College Students


Campus:

Semester:

Program:

Personal Info.









School Info.




List two faculty recommendations. At least one should be your major.

Veteran?
Time basis and shifts you would accept:









Do you have your own transportation?
Skills

Indicate your job skills by checking the appropriate box
(or send resumé via email to fran.white@kctcs.edu)

















Current/Most Recent Employer

List previous employers starting with most recent/current












Previous Employer









Previous Employer






By submitting this form, I authorize the JCTC CREW Center or it designated representative to disclose this information to prospective employers in conjunction with placement. I further authorize the JCC Office or its representative to have access to my academic records. I understand that no part of my academic records will be disclosed to a prospective employer other than information contained on this form, unless I approve such disclosure on a separate authorized form.

All applicants meeting the appropriate requirements and technical standards shall be considered equally for admission to a community college or an academic program thereof, regardless of race, color, religion, sex, marital status, national origin, age or disability.