Office of Career Services

Co-op Registration Form

Note: For more information please call (319) 273-6041.

Student Information

First Name:

Last Name:

Student ID:

E-mail Address:

Phone Number: () - (###) ### - ####

Career Services Coordinator:

Employment Profile

Employer:

Internship/Co-op Title:

Position Description:

Job Function:

Start Date: / / (MM/DD/YYYY)

End Date: / / (MM/DD/YYYY)

Hours Per Week:

Compensation: (per hour)

Company/Organization Supervisor Information

Supervisor Name:

Supervisor Title:

Supervisor Phone: () - (###) ### - ####

Supervisor E-mail:

Street Address:

City:

State:

Zip:

Academic Credit/Transcript Notation Information

Major:

Year In School:

Semester Seeking Credit:

Internship Course Number:

Number of Prior Internships/Co-ops:

Internship/Co-op Credit(s) Requested:

Academic Credit Info ONLY

Grading Type:

UNI Credit Type:

Faculty Supervisor:

Department Head:

Agreement Information

The University of Northern Iowa requests the information included in this form for the purposes of enrollment. I certify that the information provided in this enrollment form is accurate. Also, I have read and understand the UNI Cooperative Education Agreement. In addition, I understand that a late registration fee will be charged to my u-bill if I register on or after the second day of the semester. UNI Career Services will work with the Office of the Registrar to have this fee refunded, up to the last day to add a second half of the semester course. Please indicate your affirmation by checking the box below:

Yes