Universities Space Research Association – Division of Space Life Sciences
3600 Bay Area Blvd. Houston, TX 77058 ● Phone: 281-244-2000 ● Fax: 281-244-2006
Application for Student Employment
(Please complete electronically or print legibly)
Position Applied For (Job Number):
Date of Application:
How did you learn about us?
Newspaper Advertisement
University Placement Office
Friend
Relative
Walk-In
Other:
Internet Search Engine
CONTACT INFORMATION
First Name
Middle Initial:
Street Address:
Last Name:
City:
State:
Telephone Number(s)
Zip:
Social Security Number:
Home:
Cell:
E-Mail Address:
Have you ever filed an application with us before?
Yes
No
If Yes, please provide the date:
Have you ever been employed with us before?
Yes
No
If Yes, please provide the date:
Are you currently employed?
Yes
No
If yes, may we contact your present employer?
Yes
No
Are you a United States Citizen?
Yes
No
On what date would you be available for work?
Have you been convicted of a felony within the last seven (7) years?
If Yes, please explain:
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Yes
No
Universities Space Research Association – Division of Space Life Sciences
3600 Bay Area Blvd. Houston, TX 77058 ● Phone: 281-244-2000 ● Fax: 281-244-2006
EDUCATION
Name and Location of
School
Course of Study
Years
Completed
Diploma or Type
of Degree
Awarded
Undergraduate
College/University
Graduate School
Other (specify)
OTHER QUALIFICATIONS
Please describe any applicable extra-curricular activities, specialized training received, apprenticeship or jobrelated skills or qualifications acquired from employment or other experience.
OTHER ACTIVITIES AND INFORMATION
List any applicable professional, trade, business or civic activities and offices held.
You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry,
disability or other protected status.
State any additional information you feel may be helpful to us in considering your application. Also include
information that relates to your ability to perform the job for which you have applied – such as licenses,
professional membership, hobbies, etc.
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Universities Space Research Association – Division of Space Life Sciences
3600 Bay Area Blvd. Houston, TX 77058 ● Phone: 281-244-2000 ● Fax: 281-244-2006
EMPLOYMENT EXPERIENCE
Please start with your present or most recent job. If you require additional space, please use a separate sheet.
1.
Employer:
Dates Employed
From
To
Work Performed
Address:
Telephone Number(s):
Hourly Rate/Salary
Starting
Ending
Job Title:
Reason for Leaving:
2.
Employer:
Supervisor:
Dates Employed
From
To
Work Performed
Address:
Telephone Number(s):
Hourly Rate/Salary
Starting
Ending
Job Title:
Reason for Leaving:
3.
Employer:
Supervisor:
Dates Employed
From
To
Work Performed
Address:
Telephone Number(s):
Hourly Rate/Salary
Starting
Ending
Job Title:
Reason for Leaving:
4.
Employer:
Supervisor:
Dates Employed
From
To
Address:
Telephone Number(s):
Hourly Rate/Salary
Starting
Ending
Job Title:
Reason for Leaving:
Supervisor:
Page 3 of 4
Work Performed
Universities Space Research Association – Division of Space Life Sciences
3600 Bay Area Blvd. Houston, TX 77058 ● Phone: 281-244-2000 ● Fax: 281-244-2006
REFERENCES
1. Name, Title & Employee:
(
Professional
Personal)
Phone Number:
Address:
2.
Fax Number:
Name, Title & Employer:
(
Professional
Personal)
Phone Number:
Address:
3.
Fax Number:
Name, Title & Employer:
(
Professional
Personal)
Phone Number:
Address:
Fax Number:
We consider applicants for all positions without regard to race, color, religion, sex, national origin, age,
disability, or any other legally protected status pursuant to the Texas Employment Discrimination Law, and
other relevant federal, state and local laws.
I understand that submission of this application constitutes an application for employment with USRA (“the
employer”) and nothing on the application is intended to create or imply a contractual relationship. I understand
that the employer follows an employment-at-will policy, in that the employer or I may terminate my
employment at any time, or for any reason consistent with applicable state or federal law. I understand that I
must be lawfully authorized to work in the United States and I must show the employer documents that will
prove this. I understand that the employer will thoroughly investigate my work and personal history and verify
all data given on this application, on related papers, and in interviews. I authorize Universities Space Research
Association to check my references by phone, fax, e-mail or postal mail. I authorize all individuals, schools,
and firms named therein, except my current employer, if so noted, to provide any information requested about
me, and I release them from all liability for damage in providing this information.
By my signature below, I certify that all the statements herein are true and correct to best of my knowledge and
that any falsifications or willful omission on this application shall be sufficient cause for dismissal from or
refusal of employment.
Applicant Signature:
Applicant Printed Name:
Date:
FOR PERSONNEL DEPARTMENT USE ONLY
Position(s) Applied For Is Open?
Position(s) Considered For:
YES
Date:
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NO