Cooperative Education

Program Application
Student Information
Last Name

First Name

University Attending
Expected Graduation

Bronco # (Cal Poly Pomona Student)

GPA

Major
Student Status:
part-time full-time

Class Standing

Address

City

Home Number
Citizen: Yes No

M.I.

State

Cell Number
Resident: Yes No

Zip

Email Address

International Student: Yes No

Financial Aid Student: Yes No

Emergency Contact Information

Last Name

First Name

Address
Home Number

Relationship to student

City

State

Cell Number

Zip

Email Address

Employment Information
1. Have you been previously employed by the Cal Poly Foundation Office? Yes No
2. Have you ever been a CalPERS Member? Yes No (To check your CalPERS status, call Foundation HR at (909) 869-2950)
3. If you are a Cal Poly Pomona Student, are you currently employed on campus? Yes No

If yes, what Department/College are you working for:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand
that any false or misleading information could result in my release from the program and separation from my internship.
If I am hired for a Cooperative Education position, I agree to enroll for a Co-op/Internship course designated by my
advisor/university. I also understand that I must maintain enrollment in such course for the duration of my internship and/or
graduation. If a course is not available through my university, enrollment through Cal Poly Pomonas Office of the Extended
University will be a requirement.
Non Cal Poly Pomona students must send the Cooperative Education Coordinator proof of enrollment every quarter/semester until
their internship has ended and/or graduation.

Signature:

Date:
3801 W. Temple Ave. (Building 1 Room 108) Pomona, CA 91768 Tel: (909) 869-3434 Fax: (909) 869-4396
www.csupomona.edu/~cce

Rev. 11/21/2013