TO BE COMPLETED BY STUDENT:

STUDENT NAME_____________________________________ M NUMBER ______________________

COURSE NAME______________________________________ENTRY NO.________________________________

NAME OF WORK PLACE_______________________________________________________________________

SEMESTER______________________________________________YEAR________________________________

STUDENT SIGNATURE_______________________________________________DATE____________________

TO BE COMPLETED BY ACADEMIC DEPARTMENT:
Please check the appropriate response to the questions below:

1.  I am aware and fully support the student's participation in the co-op
    assignment with the company listed above during the listed time frame.            _______YES  _______NO

2.  The student's participation in the co-op class will count as an elective.              _______YES _______NO

3.   Additional materials will be provided by the Academic Department                 _______YES _______NO

4.  To receive academic credit, the student must complete an extra project.           _______YES _______NO
    If yes, please explain:
    ______________________________________________________________________________________

    ______________________________________________________________________________________

ADVISOR NAME________________________________________________________________________
                                                                                                     
DEPT. CHAIR SIGNATURE______________________________________________DATE_______________

TO BE COMPLETED BY CAREER SERVICES:

STUDENTS MAJOR/MINOR_______________________________CLASSIFICATION_____________________

CURRENT GPA_____________HOURS EARNED_______________INTERNATIONAL STATUS_____________

CO-OP COORD. SIGNATURE___________________________________________DATE__________________

  Murray State University is an equal education and employment opportunity, M/F/D,AA employer.