** = Required Field



**First Name:
**Last Name:
**G-Number:
**Email Address:
**Primary Phone #:
**Local Address (Address, City, State, Zip):

**Check Emphasis(es): 
Electrical
Computer
Mechanical
PDM
Interdisciplinary

 **Check Co-op Semester:
Spring/Summer
Fall
Winter

 **Check Co-op:
EGR 290 Co-op I
EGR 390 Co-op II
EGR 490 Co-op III
**Co-op Employer (company):
**Co-op Employer Address (Address, City, State, Zip):
**Who is your immediate supervisor?
**What is their title?
**What is your immediate supervisor's Phone number?
**What is your immediate supervisor's Email Address?
**Who does your immediate supervisor report to and what is their title?
**Who is the next level manager?
**What is their title?