John A. Logan College 
Cooperative Work/Study Program Application
General Information: (Please print information in the appropriate blanks)
 

Name:________________________________________________________________________________
Last 
First
MI

 

Telephone Number__________________________ Social Security Number_______________________

Current 
Address:______________________________________________________________________________
Street
City
State
Zip


Education:  Attach class schedule for the semester in which the student is applying to serve internship.  Note on the line below a faculty member we may use as a reference.
 
Major: ______________________________________________________________________________
______________________________________________________________________________

Work History:  If never employed please check here: 
 
Current or last employer: ____________________________________________
Direct Supervisor's Name (Mr./Mrs.) ____________________________________________
Dates Employed:___________________ Telephone Number(_____)_______________________
Day Mo Yr to Day Mo Yr

May we contact your last supervisor?  Yes  No

Have you ever been convicted of a crime other than a minor traffic violation? (Disclosure of a criminal record will not necessarily disqualify you from employment consideration.  Each offense will be evaluated on its own worth with respect to time, circumstance, and seriousness, and the relationship to the job in which you are applying.)

If yes, explain__________________________________________________________________________

(Attach seperate sheet if necessary)

Career Plans Please attach to application a typed paragraph no longer than 200 words describing your career goals and why receiving an internship with an area employer is important to you.

Resume:  Attach a current typed resume to application.

I have read and understand this application.  I've filled out the questions accurately and to the best of my ability.
  
________________________________
 
Signature
Date

 
Please return completed application to:
 

 

 Ms. Cheryl Diedrick
Cooperative Work/Study Program
John A. Logan College
700 Logan College Room G204
Carterville, IL 62918
John A. Logan College Use Only
Application received by: 
________________________________________
 
Employee Name
Date