Student Employment

Last Name:    

First Name:    

Middle Initial:

University Address:                        

Phone:   E-Mail Address:

Home Address:   

Phone:

Date of Birth:  

Birth Place:

Major:      GPA:      

Academic Year: Freshman, First Semester Freshman, Second Semester Sophomore, First Semester Sophomore, Second Semester Junior, First Semester Junior, Second Semester Senior, First Semester Senior, Second Semester Grad Student

Have you ever been placed on academic or dormitory probation? 
Yes  No

Do you qualify for work study?
Yes No     

Are the necessary forms submitted to Financial Aid? 
Yes  No

Have you ever been charged with a criminal offense?  
Yes   No     

If yes, explain in the box below:

Do you possess a valid driver's license?       
Yes   No     State     

In the box below, list organizations to which you belong, both on and off campus                                             

For which semester(s) are you seeking employment?  Summer 2008 Fall Semester 2008 Spring Semester 2009

Are you available to work over breaks?  
Yes    No

Are you willing to work evenings and weekends as may be requested?   
Yes  No

Have you ever been dismissed to asked to resign from any employment?  
Yes    No

Most Recent Place of  Employment:  Company Name: 

Company Address:  

Supervisor:

Other Employment:

Company Name 

Company Address:

Supervisor 

List four people (not relatives) who are responsible adults of
reputable standing in their communities who may serve as
references to your ability and character:

1.  Name:   Phone:  

Association:

Address:

2.  Name:   Phone:  

Association:

Address:

3. Name:   Phone:  

Association:   

Address:

4. Name:   Phone:  

Association:       

Address:

List any skills beneficial to Public Safety that you possess.  Include
skills such as CPR, computer proficiency and other related clerical skills:

By submitting this application, I certify that the information given is true and
correct and do hereby grant Public Safety permission to perform any background
investigations of my criminal history.

I wish to apply for:   Front Desk Assistant

                             Student Dispatcher/Student Officer    

                             Safety Assistant

                             Residence Hall Security Aide