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.

Contact Info: