Please fill in the form below within ONE WEEK after you begin work. Then, click the submit button to send the form via email. You will receive a copy of the email for your records.
First Name: Last Name:
Co-op Semester: Co-op Number:
Student ID: Academic Dept: CECS CEE ChemE ECE IE ME
Telephone #: E-mail:
Present Address:
City: State: Zip:
Company Name: Your Telephone #:
Company Address:
Department Assigned:
Supervisor Name: Title:
Job Duties:
Hours worked per week: Hourly Wage:
