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