Dallas County Community College District

INTERNSHIP/PRACTICUM/COOPERATIVE EDUCATION

Student Application

 

 

Year Semester/Course Number: _____________________________________

 

Instructor: _____________________________________________________________________________

 

Name:   ________________________________________________________________________________

                                     Last                                         First                                         Mi

 

Social Security Number or Student ID:  _________________________

 

Email address: _____________________________________________

 

Day Area/Phone: ____________________________    Night Area/Phone: ____________________________                                       

Degree Program:  _______________________________________________________________         

 

Work Schedule:

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday

 

Class Schedule:

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

 

Hours Worked Weekly: __________________________                                   

 

Present Employer: __________________________________________________________________________                                                                                              

Employer Address: __________________________________________________________________________

Street                                                   City                                                      State    Zip

 

Employer Area/Phone:  __________________________________

 

 

 

 

 

	Educational opportunities are offered by the Dallas County Community College District without regard to race, color, age, national origin, religion sex, or disability.