(PLEASE TYPE OR PRINT)
NAME:______________________________________________________ STUDENT #: ______________
(LAST), (FIRST) (M.I.)
HOME ADDRESS: _____________________________________________________________________
(STREET) (CITY) (ZIP)
HOME PHONE NUMBER : ( ) _________________ E-MAIL : ______________________________
COLLEGE MAJOR: ______________________CAREER OBJECTIVE: ___________________________
GPA: ______________ UNITS COMPLETED (AT CERRITOS COLLEGE) : ______________________
CERTIFICATES COMPLETED: ____________________________________________________________
DEGREES COMPLETED: ________________________________ WHERE: ______________________
DEGREES COMPLETED: ________________________________ WHERE: ______________________
COURSES TAKEN: INDICATE GRADE IF COMPLETED OR INDICATE “I” FOR CLASS IN PROGRESS
| ____ Comp Prog Logic | ____ Visual Basic | ____ Advanced Visual Basic |
| ____ C/C++ | ____ Object Oriented Prog C++ | ____ Data Structures |
| ____ VB Script | ____ Java | ____ Advanced Java |
____ Java Script |
____ Perl/CGI | ____ Cobol |
| ____ Advanced Cobol | ____ Report Program Generator(RPG) | ____ Adv RPG Programming |
| ____ SQL Programming | ____ Pascal | ____ Fortran |
| ____ MS Access | ____ AS/400 Operations | ____ AS/400 Control Lang Prog. |
| ____ Query 400 | ____ Unix | ____ Windows 95/98 |
| ____ MS Windows NT/2000 | ____ SQL Server Admin & Impl. | ____ TCP/IP on MS Windows NT |
| ____ HTML | ____ MS Internet Info Server (IIS) | ____ Windows NT Workstation |
| ____ Network Fundamentals | ____ Local Area Networks | ____ Wide Area Networks |
| ____ Networking Architectures | ____ Internetworking | ____ Networking Protocols |
| ____ Net Analysis & Design | ____ LAN (Novell) | ____ Other: _________________ |
| ____ System Design & Analysis | ____ Adv. System Design & Analysis | ____________________________ |
(PLEASE TYPE OR PRINT)
CURRENT EMPLOYER (if any)
JOB TITLE: ______________________________ LENGTH OF EMPLOYMENT: ____________________
EMPLOYER: __________________________________________________
ADDRESS: ___________________________________________________________________________
(STREET) (CITY) (ZIP)
IMMEDIATE SUPERVISOR: ____________________________________ TITLE: ___________________
SUPERVISOR PHONE NUMBER: ( ) _______________________ EXTENSION: ______________
CURRENT WORK SCHEDULE:
SCHOOL SCHEDULE:
PREFER: ____ON CAMPUS OR ____OFF-CAMPUS INTERNSHIP
ARE YOU WILLING TO KEEP YOUR CURRENT JOB? Y / N
WILL YOU WORK IN ADDITION TO YOUR CURRENT JOB? Y / N
ARE YOU WILLING TO TRAVEL/ COMMUTE TO WORK? Y / N IF SO, HOW FAR ____________
I CERTIFY THAT THE ABOVE STATEMENTS ARE TRUE AND I UNDERSTAND THAT ANY MISREPRESENTATION OF FACTS IS GROUNDS FOR DISMISSAL FROM THE WORK EXPERIENCE PROGRAM.
__________________________________________________________
STUDENT’S SIGNATURE DATE