Student Employment Application
INDIANA UNIVERSITY PURDUE UNIVERSITY FORT WAYNE
DATE:
Personal Information:
NAME:
STUDENT ID NUMBER:
(FIRST)
(LAST)
(MI)
PRESENT ADDRESS:
(STREET)
(CITY)
TELEPHONE:
U.S. Citizen?
(STATE)
(ZIP CODE)
EMAIL:
YES
NO
If No, Do You Have a
J-1 Visa
Have You Been Approved & Have You Accepted Work Study through Financial Aid?
YES
Have You Been Using your Work Study Award in another Department?
YES
F-1 Visa?
NO
NO
Date Award Accepted
Date First Worked
Major:
Hours Enrolled:
Hours of Availability (Please mark the hours that you are available):
7am
8am
6pm
9am
9am
10am
10am
11am
12pm
1pm
2pm
3pm
4pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
8am
11am
12pm
1pm
2pm
3pm
4pm
5pm
5pm
6pm
Position for Which You Are Applying:
Clerical Or Technical Skills You Possess:
Employment History:
Employer (include current employer) Dates (month/year) Location (city/state)
Phone
Job Title
In Case of A medical Emergency Please Contact:
Name:
Phone:
Address:
Relationship:
If employed, I will be subject to and agree to comply with policies, rules and regulations of the University and I agree to use safe working
techniques and all safety equipment required. I understand that any false statement by me in this application or failure to give any material
information requested will be caused for my rejection or dismissal.
Have you ever been convicted of a crime (include courts-material convictions, but exclude minor traffic violations?
Yes
No
If yes, list date, charge, place, court and action taken
I understand that employment in certain jobs is conditional upon a review of criminal conviction records. I authorize the University to
request and obtain, through the Indiana State Police, an investigation and report to determine the accuracy of my above answers as to
prior criminal convictions, if any.
Applicant’s Signature:
Date: