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op interest

Cooperative Education and Internship Program (CEIP)   College of Engineering 

Student Interest Form

Please complete this form. Thank you!

Fill out the information requested below and, when done, click the "Submit Form" button. Use the tab key to move between fields. Note that the Enter Key will submit the form before it is completed.

Items marked * are required fields!

Personal Information   
Last Name      *    
First/Middle Name      *   (First Middle)    
Student Identification Number      *   (NOT your SSN)    
Degree Information   
Classification   
 Freshman  Sophomore  Junior  Transfer
   
Major        
Minor        
Projected Date of Graduation   
 Fall  Spring  Summer
Year 20    
Advisor        
Citizenship   
Citizenship   
 U.S. Citizen
 Permanent Resident
 Visa Holder
   
Visa status (If Visa Holder)       
Local/On Campus Address   
Street Address       
City       
State       
Zip Code       
Daytime Phone      (###-###-####)   
Evening Phone      (###-###-####)   
Cell Phone      (###-###-####)   
School Email     @umassd.edu  *   
Permanent Address (if different)   
Street Address       
City       
State/ Province       
Country       
Zip Code       
Phone       
Permanent Email        
Guardian's Information   
Parent(s)/ Guardian(s) Last Name        
Parent(s)/ Guardian(s) First/Middle Name       (First Middle)    
Street Address (If different)       
City       
State/Province       
Country       
Zip Code       
Phone       

Agreement   
 I accept the invitation to enroll in the Cooperative Education and Internship Program.   *   
 I agree to attend the required Pre-Placement Seminar/ Workshop.   *   
Desired track/ path   
 CI-1  C-1  C-2  Other   *
   
Signature      (Please Initial Here)   *    
Security Image:    * Security Image Audio Icon Refresh Icon    

Please verify all the information before submitting the form. A confirmation will be sent to your school Email address. Please contact the Cooperative Education and Internship Program office if you do not receive a confirmation Email, noticed any discrepancies or need to make any changes. Thank you for submitting the form.

   

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