Student Employment Application (Page 2 of 2) in pdf

Student Employment Application Page 2

Are you eligible for Federal Work Study?

Yes

Are you a U.S. citizen?

Yes

In no, are you authorized to work in the U.S.? Yes No

Are you 18 years of age?

Yes

If no, have you provided a work permit?

Yes No

Please list relevant paid or volunteer work experience:

1. Employer/Department ______________________________

Position ______________________________

Address ____________________________________________ Phone ________________________________

Supervisor __________________________________________ Dates of employment: From ______ to ______

2. Employer/Department ______________________________

Position ______________________________

Address ____________________________________________ Phone ________________________________

Supervisor __________________________________________ Dates of employment: From ______ to ______

3. Employer/Department ______________________________

Position ______________________________

Address ____________________________________________ Phone ________________________________

Supervisor __________________________________________ Dates of employment: From ______ to ______

References:

1. _________________________________________________________________________________________

Full Name

Phone number

Relationship

2. ________________________________________________________________________________________

Full Name

Phone number

Relationship

3. ________________________________________________________________________________________

Full Name

Phone number

Relationship

I authorize you to contact the references listed above, and I hereby certify that the above information is true and

complete. I understand that falsification or omission may result in my termination from student employment.

__________________________________________________________________________________________

Signature

Date

m/stud empl FY07/word/D-jobapplication7-28-04

Student Employment Application Page 2