Work-Based Learning Employer Application

Work-Based Learning Employer Application

Thank you for participating in Work-Based Learning/Cooperative Education!
This application gives Lower Columbia College (LCC) the information that we need to generate an affiliation agreement with your company. The affiliation agreement ensures that the guidelines for all parties are established to keep processes running smoothly.
Name of organizational official with authorization to sign agreements on behalf of the company*

First NameLast Name
Title*
Department*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Work Site Information

Please provide as much information as possible
Name of Work Site/Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Trainer (if known)

First NameLast Name
Trainer Phone
Please enter a valid phone number.
Trainer Email
example@example.com
Student Referral or Application
Please indicate your preferred intake process for a potential intern.
Submission of this Form

By submitting this form, you are requesting company alignment with Lower Columbia College's Work-Based Learning/Cooperative Education/Career Connect WA programs. An Affiliation agreement will be generated using the information provided on this form.
Lower Columbia College does not discriminate on the basis of sex and prohibits sex discrimination in any education program or activity that it operates, as required by Title IX, including in admission and employment. Lower Columbia College provides equal opportunity in education and employment and does not discriminate on the basis of race, color, national origin, citizenship or immigration status, age, perceived or actual physical or mental disability, pregnancy, genetic information, sex, sexual orientation, gender identity, marital status, creed, religion, veteran or military status, or use of a trained guide dog or service animal as required by Title VI of the Civil Rights Act of 1964, Title VII of the Civil Rights Act of 1964, Title IX of the Educational Amendments of 1972, Sections 504 and 508 of the Rehabilitation Act of 1973, the Americans with Disabilities Act and ADA Amendment Act, the Age Discrimination Act of 1975, the Violence Against Women Reauthorization Act and Washington State's Law Against Discrimination, Chapter 49.60 RCW and their implementing regulations. All inquiries regarding compliance with Title IX, access, equal opportunity and/or grievance procedures should be directed to Vice President of Foundation, HR & Legal Affairs, 1600 Maple Street, PO Box 3010, Longview, WA 98632, title9@lowercolumbia.edu, Phone number, (360) 442-2120, Phone number/TTY (800) 833-6388. The notice of nondiscrimination is located at https://lowercolumbia.edu/disclosure/non-discrimination/.
Should be Empty:

Work-Based Learning Employer Application

Work Site Information

Submission of this Form