Student Employment/ Cooperative Education Release Form

Student Employment/ Cooperative Education Application and Release Form

To submit the Release Form online complete the form below and click Submit at the bottom of the page.

If you prefer to submit the Release Form by fax or mail, you may download the form in the following format: Microsoft Word or Adobe Acrobat
(Note: You may Download Adobe Acrobat reader to view the Release Form. )

Major/Area of Study:	G Number: or SSN:	(8 digit of Student G Number: G12345678) (9 digits of SSN: 940-00-0000)
Degree(s)/Certificate(s) held:

Name:
Address:
City:	State:		Zip:
Phone:	Email:

Are you authorized to work in the United States? http://www.pcc.edu/pcc/pro/progs/internat/default.htm	Yes	No
Are you interested in Cooperative Education credit? http://www.pcc.edu/pcc/res/careers_jobs/coop/coop_ed.htm	Yes	No
Would you accept a non-paid Cooperative Education position?	Yes	No
Comments (goals, type of positions, etc.):

Consent to Release Confidential Information Portland Community College shall follow all applicable state and federal laws, rules and regulations that apply to student records. All information contained in the college records which is personally identifiable to any student shall be kept confidential and not released except upon prior written consent of the student or upon lawful subpoena or other order of a court of competent jurisdiction. Pursuant to my employment search, I hereby authorize PCC to release confidential information about me contained in the college records or documents on file in the Student Employment and Cooperative Education Office to all potential employers. PCC can not release job-related information to potential employers without submitting this form and agreeing with the terms and condition of this Release Form.
By checking this box, I agree with the terms and conditions of this Release Form and hereby authorize PCC to release confidential information about me.		*Date:*		(MM/DD/YYYY)

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Send comments or suggestions regarding Student Employment and Cooperative Education pages to: Gary Coleman

Copyright 1996 - 2010, Portland Community College
An Affirmative Action, Equal Opportunity Institution.

Last Modified: July 2010