Hall Floor Dates Living-Learning Community (if applies)

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Residential Life Office
Indiana State University
Academic Peer Advocate (APA)
Application 2011-2012
Full Name:
Student ID Number (991): __
Last
First
________________
Middle
Date:
Local Information
Address:
Street Address
Telephone: (
)
City
State
Zip
Email Address (@sycamores.indstate.edu):
Permanent Information
Address:
Street Address
Telephone: (
)
City
State
Zip
Email Address (@sycamores.indstate.edu):
Academic Information
Classification:
Major:____
Minor:____
FR
SO
JR
SR
GR
Are you a transfer student?
Yes
No
If “Yes,” Name your previous institution:
____
_____
Anticipated Graduation Date:
Semester Grade Point Average:
Cumulative Grade Point Average:
List Any Academic Awards or Honors Societies:
Housing History
Number of Semesters in University Housing:
Hall
Floor
Dates
Living-Learning Community (if applies)
Hall
Floor
Dates
Living-Learning Community (if applies)
Hall
Floor
Dates
Living-Learning Community (if applies)
Hall
Floor
Dates
Living-Learning Community (if applies)
Personal Information
Please list your extracurricular activities and community service involvement. Please use additional paper if
needed.
Organization Name
Position
Dates
Organization Name
Position
Dates
Organization Name
Position
Dates
Organization Name
Position
Dates
Organization Name
Position
Dates
Community Service
Position (if applies)
Dates
Community Service
Position (if applies)
Dates
Hobbies, leisure activities:
Employment History
Please list your past employment history:
Company Name
Position
Dates
Company Name
Position
Dates
Company Name
Position
Dates
Company Name
Position
Dates
Short Answer:
Please read then reflect on each of the following short answer questions. Applicants are required to answer all questions.
All questions should be typed and must not exceed two double spaced pages.
1.) What qualities do you feel make a positive academic community and how have you contributed to an
academic community?
2.) How can you use your personal experience transitioning from high school to college to assist other
students who are struggling with their academics and transition?
3.) What qualities and skills do you possess and that would make you a successful Academic Peer Advocate?
4.) What do you hope to gain from the Academic Peer Advocate position?
Release of Information
I, ____
___________________________________, give my permission for Indiana State University to release
pertinent information, which has been or will be requested by the Residential Life Office. I understand that my grades,
conduct records and status with the International Affairs Center will be checked during the selection process and, if hired,
at any time during my term of employment.
Signature
Date
References: Please provide the names and relationship (Faculty, employer, residence hall staff) of the people you are
asking to complete the reference forms. All reference forms must be returned by the application deadline for your
application to be considered.
Name
Relationship
Name
Relationship
Interviews:
The Student Staff Interviews will be held in the evening of November 8th and 9th. Once your application, essay
responses, and references are received, we will contact you to schedule your interview time and remaining
selection process. Please check your preference below (Please note, we will try to accommodate your request,
however no guarantee can be made that you will receive your chosen day).
Tuesday, November 8th
Wednesday, November 9th
Application are due by October 21, 2011 at 4:30pm
Please submit your completed application and reference forms either:
Electronically to: [email protected]
OR
Hardcopy to:
Residential Life Office
Indiana State University
Terre Haute, IN 47809
Phone: (812) 237-3993 Fax: (812) 237-8525
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