Job Request Form

Company Information

* Company Name:

Parent Company Name (If Applicable):

* Company Web Address (URL):

* Company Description / Mission:

Company Groupings:
Minority Owned Woman Owned Other/Unknown

Contact Information

* Primary Contact - First Name:

* Primary Contact - Last Name:

* Contact Email Address: Check if contact does not have email.

* Phone (Include Area Code):

* Fax (Include Area Code):

* Street Address 1:

Street Address 2:

* City:

* State:

* Zip:

* Will the primary supervisor be someone other than the primary contact?
Yes No

Full Name of Supervisor (If Yes):

Email Address of Supervisor (If Yes):

* Will students be working at the same location listed above? Yes No

If the answer above is NO, then please provide work location information:

Location Contact - Full Name:

Phone:

Fax:

Contact Email:

Street Address 1:

Street Address 2:

City:

State:

Zip:

Country (Other than United States):

Job Information:

* Co-op Job Title:

* Wages Minimum ($/hour):

* Wages Maximum ($/hour):

* Average Hours per Week

* Number of Openings

* Minimum Required GPA (NEU Minimum is 2.00)

* Major(s) to Make Available:
Anthropology
Sociology
Human Services
Other, Please specify:

Job Description

Goals & Objectives:

* Description of Duties:

* Describe how the Co-op Student will reach Job Location (e.g., access to public transportation?) In addition, if your company website has "Directions" link, please enter it in the space below.

Additional Qualifications Desired:

Skills Desired (e.g., computer skills, analytical skills, problem solving):

Personal Qualities Desired (e.g., ability to work independently, ability to multi-task):