Employer Information

If you are an employer interested in having students work in a cooperative learning, internship, or practicum experience at your company, please complete the following form.

If you would rather have a printable form click here.

Today's Date:
WBL Experience Location/Company Name:

Supervisor/Contact:  
                       Title:
Company Address: 
Company City:     State:    Zip: 

Phone:         Alternate Phone Number:   
Email:   

Company Scope [type of business and brief description]:

Date needed to start work:
Salary Amount or Range: $ /hour
Job/Area Title/Department:

Work/Times needed:
Full-time 35 or more hours per week)
Part-time (10-34 hours per week)

Work/Days needed: Days Evenings Weekends Rotating Shifts

Experience Desired:

Other Information:

Thank you for your posting, information submitted will be confidential.

Work-Based Learning Coordinator:
John J. Back, Technical Campus, email: JohnJ.Back@kctcs.edu,
Office: Technical Campus, Devert Owens, Room XX, phone: 606-487-3301