Jefferson Community College Application
for internship, cooperative or experiential education

Campus:

DowntownSouthwestCarrolton

Semester:

FallSpringSummer

Program:

Co-opInternshipExperiential Education

Personal Info.

Full Name

Address

Zip Home Phone

Email Address

Work Phone Cell Phone

Date of Birth Empl I.D.

Emergency Contact: Phone

School Info.

Major Advisor

Semester hours completed at JCC GPA

List any other colleges attended other than JCC

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

1

2

Work Related

Veteran?

Yes
no

Time basis and shifts you would accept:

full-time
permanent
evenings
rotating shifts
part-time
temporary
weekends
salary desired

Date Available to work:

Do you have your own transportation?

Yes
No

Any physical limitations?

Skills

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

Word Processing
Spreadsheet
Accounting
Supervisory
Legal Terminology
Sales
Computer Networking
Computer Repair
HTML
C+
Visual Basic
Java
PHP
Medical Terminology
Other

List previous employers starting with most recent/current

Current/Most Recent Employer

Start Date End Date

Company Name & Address


Job Title

Salary Hrs. per Wk

Supervisor's Name

Reason for Leaving

Previous Employer

Start Date End Date

Company Name & Address


Job Title

Salary Hrs. per Wk

Supervisor's Name

Reason for Leaving

Previous Employer

Start Date End Date

Company Name & Address


Job Title

Salary Hrs. per Wk

Supervisor's Name

Reason for Leaving

I authorize the JCC 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.