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case western reserve university

Office of Engineering
Student Programs
 

Notification of Graduate Co-op Assignment

Please complete this form within the first three (3) weeks of your coop assignment. The Co-op office will contact you for a variety of reasons while you are on Co-op. It is very important that we have this information so we can forward paperwork to you and your supervisors throughout your Co-op. You can either submit this form online or download and return the completed form to:

Cooperative Education Program
Case Western Reserve University
Nord Bldg.- Room 304, 10900 Euclid Avenue
Cleveland, OH. 44106-7240
Fax: 216-368-0327
Personal Information:
While on Co-op I will be Residing at:
Last Name: Street:
First Name: City:
Major: State: Zip:
Email Address: Country:
Alternate Email: Phone:
Information about Co-op Assignment:
Company: Supervisor's Title:
Street: Your Phone:
City: Assignment Duration:
State: Zip: This is your:
Mail Stop: Health Insurance?
Country: Tuition Reimbursement?
Supervisor's Name: Relocation Assistance?
Supervisor's Phone: If yes, how much?:
Monthly Salary: Other Company Benefits:
Start Date (MM/DD/YY): End Date (MM/DD/YY):

Additional comments or suggestions: