Houston Community College System
Form COOP-2
 DFTG-2380 COOPERATIVE EDUCATION 1
 DFTG-2381 COOPERATIVE EDUCATION 2
14-0116
COOPERATIVE EDUCATION - STUDENT APPLICATION
GENERAL INFORMATION
Name (print please) ________________________________________________ Gender:  Male
First
Mi
 Female
Last
Program (Major):
Semester: ___________ Yr: 20 _____
(If undecided, please determine by mid-semester)
Estimated Graduation date: ______________ S/S No (last 4 digit only):_______ Date of birth _____________
Telephone: Home:____________________
Mobile: __________________ Other: ______________________
Email address: ________________________________ Alternate email: ______________________________
Mailing Address: _____________________________________________________ Zip: _________
EMPLOYMENT INFORMATION
Yes
Are you currently employed?
No
(For office use only)
If Employed, please answer the following:
Job Title: ____________________________ Work Phone Number: _____________________
Name of Company: ____________________________ Name of Supervisor: ________________
Company phone: _______________________
Office Phone: __________________________
Company Address: ____________________________________________ Zip: _____________
COOPERATIVE EDUCATION INFORMATION
Are you currently enrolled at HCCS?
Yes
No
__________________
Number of courses you have completed?
______
GPA: _____
__________________
Interview with Co-Op Instructor?
Yes
No
__________________
Work Agreement/Training Plan Filed?
Yes
No
__________________
Date verified/Waived
Date verified/Waived
Date verified/Waived
Date verified/Waived
In Applying For A Co-Op Program, I Understand That:
1. My work assignment will be made by my coordinator and may not be the preference I have indicated. It will reflect the
best balance among my interests, sponsor’s interest and my coordinator’s judgment. The coordinator may release
copies of my unofficial college transcript to prospective and current co-op sponsor.
2. Pay rate while on Co-Op is negotiated between the sponsor and the student and is not controlled by the college.
3. I will be expected to sign a Co-Op Training Plan that will identify my Co-Op sponsor, rate of pay and conditions of
employment.
4. I will supply a transcript and written resume if requested by the Co-Op Education Office.
5. I am expected to honor my commitment to the Co-Op program unless circumstances unknown to me now prevent my
doing so.
I hereby apply for admission to the Co-Op program.
Student’s signature
Date
Approved by: __________________________________ Position: _________________
(HCCS Faculty)
Date: __________________