Application for Employment
Student Activities
Office 350, Kehr Union Building
nd
400 East 2 St., Bloomsburg, PA 17815
Phone: 570-389-4346 | Fax: 570-389-2615
For Internal Use Only
Received Date
Hired Date
Do not write in this space
Work Area
FAFSA
Student Standards
Personal Data
Name:
Cell Phone: (
BU Student ID #:
Home Phone: (
Please Print
Year in School:
Freshman
Junior
Sophomore
Senior
School Address:
City
Zip
Major:
Spring
Fall
City
State
Zip
Position Applying For:
Reservation Asst
Summer
Home Address:
)
E-mail Address:
Interested In:
State
)
Events Mgmt Asst.
Games Rm Attendant
Technical Crew
Office Assistant
Setup Crew
KUB Desk Assistant
Preference
Order:
______
______
______
______
______
______
______
Work Experience (Please list two experiences below or include a copy of your current resume)
Title / Position Name
Employer Name
Address
City
Phone Number
Dates of Employment
Title / Position Name
Employer Name
Address
City
Phone Number
Dates of Employment
Updated 7/28/12
Describe Position & Responsibilities below:
State
From:
Zip
To:
Describe Position & Responsibilities below:
State
From:
Zip
To:
Page 1 of 2
Special qualifications, skills, abilities
Activities, Organizations, Honors, Volunteer Services
References
Name (please print)
1.
2.
3.
Relationship
Phone Number
(
)
(
)
(
)
These questions are required for the review of your application.
Please complete and attach your answers.
1. What do you know about the Kehr Union and the position that you are applying for?
2. Explain why you want to work in the Kehr Union.
3. Describe your work ethics; give an example as to how your work ethic would apply to this
position.
DISCIPLINARY RECORDS CONSENT
I hereby authorize my consent for the release of any and all information pertaining to my University judicial/disciplinary
records on file in the Office of Student Standards for the purpose of University employment and/or membership in extracurricular activities. This information will only be made available and/or requested by those individuals who have hiring
and/or supervisory responsibilities.
This consent remains in effect for the duration of my employment/participation in extra-curricular activities.
Furthermore, I understand that my signature below indicates that the information that I have provided above is correct and
complete to the best of my knowledge.
Signature:
Date:
Signature required at time of application
SUBMISSION OPTIONS:
1)
2)
3)
Save (Microsoft Word) document; attach to e-mail, submit to: ststudac@bloomu.edu.
NOTE: Applications cannot be processed without a written signature authorizing consent to release disciplinary records. Failure to
provide consent may delay your employment start date.
nd
Print document; deliver/mail to: Student Activities Office, 350 Kehr Union Building, 400 East 2 St., Bloomsburg, PA 17815.
Print document; fax to: 570-389-2615, Attn: KUB Student Employment.
Bloomsburg University of Pennsylvania is committed to affirmative action by way of providing equal educational and employment opportunities for all persons
without regard to race, religion, gender, age, national origin, sexual orientation, disability or veteran status.
A Member of Pennsylvania’s State System of Higher Education.
Page 2 of 2
WAIVER FORM; DISCIPLINE WAIVER
University Requester Information:
Name
Dean of Students Office
Kehr Union Building
Bloomsburg University
Title
Contact Information (extention/email address)
A release of discipline waiver form must be filled out and returned to the Dean of Students Office for any
disciplinary/judicial information to be released to a requesting party. Upon receipt of this form The Dean of
Students Office will forward a student’s disciplinary status to the requesting party.
Student Name
BUID
Current Address
Cell Phone
Email Address
PLEASE SELECT A REASON FOR WAIVER:
Social clearance

Academic requirement- list department_________________________________________________________
Membership in extra-curricular activities- list activity______________________________________________
University employment- List Office and/or position________________________________________________
Other- Explain______________________________________________________________________________
WAIVER VERIFICATION:
I,________________________________________ hereby authorize my consent for the release of any and all
information pertaining to my University Judicial/Disciplinary records on file in The Dean of Students Office for
the purpose as indicated above. This information may only be made available and/or requested by those
individuals who have supervisory/advising/hiring responsibilities and will remain in effect for the duration of my
employment/involvement/relationship with the above listed reason.
Student Print Name
Student Signature
OFFICE USE ONLY:
Date Received__________ By__________ (initials)
Describe Disciplinary Status:
Status sent to:
Date Sent:
Date