Application For Placement

CO-OPERATIVE EDUCATION APPLICATION FORM

Student:	Parent/Guardian:
Address: City: Postal Code:
Phone: email address:	S.I.N:
Age:	Date of Birth:
School average:	Number of absences in present semester: Number of lates in present semester:

Career Goal: ___________________________________________________________________________________

Subject related to Co-op placement request:

1. ____________________________________ Mark __________

Circle the appropriate response to the following questions.

Have you ever been convicted of a Federal Offence for which you have not received a pardon? Yes/No
Are there any charges or investigations pending that may affect or restrict your placement in this program? Yes/No
Are there conditions or restrictions that may prevent you form participating in a specific placement? Yes/No
(e.g. trespassing, shoplifting, court order, etc.)

Student Signature: _____________________________________________________________________________

Office Use Only

[ ] Student Handbook [ ] Resume [ ] Cover Letter

PLACEMENT DESIRED (List in order of preference)
1.
2.
PLACEMENT:	PLACEMENT:
Contact Person:	Contact Person:
Address: Phone:	Address: Phone:
In-School Component:	Out of School Component:

Please return application to Mr. Hinton by: _______________________________________________
Application Home Page