COMPLETE AND RETURN TO YOUR INSTRUCTOR

STUDENT APPLICATION

Computer and Information Technology
Working Connections 2000
Work Experience/Internship Program

PLEASE TYPE OR PRINT

Name: _____________________________________________________ Student #: ______________
           (Last)                                            (First)                          (M.I.)

Home Address: _____________________________________________________________________
                         (Street)                                                             (City)                                  (Zip)

Home Phone Number (Include Area Code): (       )___________________________________________

Occupational Goal: _________________________________________    Major Code: _____________

Computer Instructor’s Name: ___________________________________________________________

Computer Class Number/Name: _________________________________________________________

How many computer class units you have completed: ________________________________________

Complete this portion if you are currently working

Job Title: ________________________________________   Length of Employment: _____________

Employing Firm Name: _______________________________________________________________

Firm Address: _____________________________________________________________________

Immediate Supervisor’s Name: ____________________________    Title: _______________________

Supervisor’s Phone #: __________________________________    Extension: ___________________

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Student’s available hours for Work Experience: Full-time ______________       Part-time____________

Hours:  Day _______________               Swing __________________      Grave _________________

Previous units enrolled in Work Experience at Cerritos: _______________________________________

Other Community College(s) in California: _________________________________________________

It is my understanding that Work Experience/Internships hours are paid or unpaid. (yes) _______________
                                                                                                                                    (Write in answer)

It is my understanding that for me to receive college credit for this class, I must be enrolled in the for-credit portion of this work experience program. (yes or no) _________________
                                                                (Write in answer)
I declare that I have a full understanding of this Work Experience/Internship program, and I will abide by the rules of this program.

________________________________________________
Student’s Signature