Today's Date ________________________________
Name: __________________________________________Soc. Security # _______________________________
Major: __________________________________________ Classification: ______________________________
Campus Address: _________________________________ Campus Phone: _____________________________
Home Address: ___________________________________ Home Phone: ______________________________
E-Mail Address: __________________________________
Employment Desired: (1 = First Choice)
Senior Student Consultant __________________________
Microcomputing Site Assistant ______________________ (Site Preference) ____________________________
Date Availiable: __________________________________
Semester/Sessions Available: _______________________ Hours per week available: _____________________
Are you Workstudy: ______________________________
If yes, how much money have you been allotted for the school year? ______________________________
Are you on Academic or Disciplinary Probation? ____________________________________________________
If yes, please explain _____________________________________________________________________
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Employment Record: Please list most recent employer first.
Employer ____________________________________________________________________________________
Address ______________________________________________________________________________________
Phone Number _________________________________ From (Mo/Yr)__________ To (Mo/Yr)______________
Supervisor ____________________________________ May we contact? _______________________________
Describe Duties ______________________________________________________________________________
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