SAMPLE
Cooperative Education-Employment Contact Form

Name of Student: _________________________________________________________

Program: ________________________________________________________________

Teacher/Coordinator: ______________________________________________________

Dates of Employment: _____________________________________________________

PLEASE PRINT ALL INFORMATION BELOW
Job Information
Job Title: ______________________________________________________________________

Name of Company/Business: _____________________________________________________

Address: ______________________________________________________________________

Phone No.: ____________________________________________________________________

Contact person: ________________________________________________________________

How did you learn about the opening of this job? 

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Action Taken:
Interview Scheduled: _______ Y or ________N   

Date: ___________ Time: ________________

Name of Interviewer: __________________________________________________________

Letter of application sent: _______ Y or ________N   

Date:______________________________

Phone Number: _____________________________________________________

Date called: ________________________________________________________

Outcome: __________________________________________________________

Follow-up action needed:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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