TENNESSEE STATE UNIVERSITY
COOP WORK VERIFICATION FORM
NAME: ________________________________________________________________________
CURRENT
ADDRESS: _____________________________________________________________________
CITY: ________________________________________STATE ________ZIP CODE____________
PHONE NUMBER: (_____)_____________________________
EMPLOYER: _____________________________________________________________________
WORK SITE ADDRESS: ____________________________________________________________
CITY:_________________________________________STATE_________ZIP CODE___________
SUPERVISOR NAME:
SUPERVISOR'S TITLE:
WORK SITE PHONE #: (____ )___________________________
WORK SITE FAX: (_____)_______________________________
DESCRIPTION OF YOUR JOB ASSIGNMENT (Attach job description if available).
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
___________________________________
____________________________________
Student Signature
Supervisor Signature
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This information sheet is to be returned within two weeks of the
start of the co-op assignment.
Return to : Cooperative Education
Tennessee State University
Floyd/Payne Campus Center, Suite 306
Nashville, Tennessee 37209-1561
(615)963-7481 office
(615)963-7467 fax
bgittens@picard.tnstate.edu