Co-op Application

Co-op Application
Student Name:*

First NameLast Name
Is this a paid or unpaid position?*

PaidUnpaid
Semester you will attend FCCTC?*

Semester 1Semester 2
Employer/Name of Company:*
Supervisor's Name (If not available at time of application, please list HR representative.)*

First NameLast Name
Supervisor's Phone Number:*
Please enter a valid phone number.
Supervisor's Email:*
example@example.com

Employer Street Address*
Employer Address Line 2
Employer City*
Employer State*
Employer Zip Code*
Use the following link to find Workers' Compensation Information: http://www.dli.pa.gov/Businesses/Compensation/WC/insurance/Pages/Workers-Compensation-Insurance-Search-Form.aspx
Workers' Compensation Policy Number*
Workers' Compensation Insurance Company*
Student Age*

18 or overUnder 18
Attach a copy of your Work Permit if you are under 18 years of age.*

Cancelof
Co-op Student's Starting Wage:*
Dollars Per Hour
Student training/Work Schedule (Select all applicable)

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Vehicle information