APPLICATION FOR STUDENT/INTERMITTENT EMPLOYMENT
SECTION I (Please Print)
Position/Department Applying for:
Name:
Email:
Local Address:
Permanent Address:
Phone:
Driver’s License # (If applicable to position):
Are you 18 years or older?
Are you legally eligible for employment in the United States?
Do you have any close family members working for CPC or CPSU? If, yes, list name & relationship below.
Yes
Yes
Yes
No
No
No
NAME OF RELATIVE:
RELATIONSHIP:
Note, you may not work directly for your close relative and must disclose your relationship to HR prior to beginning employment.
Can you perform the functions of this position with or without accommodation?
Yes
No
IF YOU REQUIRE ACCOMMODATION, WHAT ACCOMMODATION COULD THE CAL POLY CORPORATION PROVIDE TO ENABLE YOU TO PERFORM THE FUNCTIONS OF THIS POSITION?
Have you ever been convicted of a crime other than traffic infractions? If yes, give details below, including date(s).
Yes
No
IF DRIVING IS PART OF THE POSITION YOU ARE APPLYING FOR, NOTE ALL TRAFFIC INFRACTIONS. Conviction is not an automatic bar to employment. Each case will be considered on its
own merits. Failure to report or omission of any convictions will result in immediate termination. Use a separate page if needed.
Have you ever been on parole or probation? If yes, provide details below, including date(s).
Yes
No
Were you ever discharged from employment? If yes, provide details below, including date(s).
Yes
No
Are you currently a member of the California Public Employees’ Retirement System?
Yes
No
If you are currently working for a CalPERS employer, what is your status? Full-time:
Part-time:
If you are an active member (funds on deposit) and working less than full-time, we will sign you up as a CalPERS member with Cal Poly Corporation
and take the following CalPERS deductions each pay period: Gross Salary – $236.77 x 5%
What machines and software programs do you operate?
What computer training/skills do you have?
Typing Speed
SECTION II
wpm
(If you are a Cal Poly student, answer the following. If you are not a Cal Poly student, skip to section III)
Graduation date from CPSU:
Class Status
Do you have a Federal Work-Study award? Yes
No
Major
Amount: $
SECTION III
WORK EXPERIENCE:
(Please list in chronological order beginning with most recent)
1. From:
To:
Job Title:
Employer Name & Address:
Supervisor’s Name:
Supervisor’s Contact Info:
Job Duties:
MUST COMPLETE PAGE 2
→
WORK EXPERIENCE continued from previous page
2. From:
To:
Job Title:
Employer Name & Address:
Supervisor’s Name:
Supervisor’s Contact Info:
Job Duties:
3. From:
To:
Job Title:
Employer Name & Address:
Supervisor’s Name:
Supervisor’s Contact Info:
Job Duties:
SECTION IV
AM
12:00-1:00
1:00-2:00
2:00-3:00
3:00-4:00
4:00-5:00
5:00-6:00
6:00-7:00
7:00-8:00
8:00-9:00
9:00-10:00
10:00-11:00
11:00-12:00
(Please show hours you are available to work below by marking the appropriate boxes)
SUN
MON
TUES
WED
THUR
FRI
SAT
PM
12:00-1:00
1:00-2:00
2:00-3:00
3:00-4:00
4:00-5:00
5:00-6:00
6:00-7:00
7:00-8:00
8:00-9:00
9:00-10:00
10:00-11:00
11:00-12:00
SUN
MON
TUES
WED
THUR
FRI
SAT
SECTION V
LIST TWO (2) REFERENCES:
NAME:
Address:
Phone Number:
NAME:
Occupation:
Address:
Phone Number:
EMERGENCY CONTACT:
Occupation:
Relationship:
Phone Number:
I hereby certify that all the information on this application is correct and complete to the best of my knowledge. I agree to have the
statements verified by the Cal Poly Corporation unless I have indicated to the contrary. I understand that falsification or omission of
any material information on this application may be considered cause for immediate dismissal. If employed, I agree to abide by all
policies and procedures established by the Cal Poly Corporation. I recognize that the relationship is at the mutual consent of the Cal
Poly Corporation and me. Consequently, either the Cal Poly Corporation or I can terminate the employment at will, with or without
cause or notice. I also understand and agree that the Company retains the right to demote, transfer, change my job duties, and
adjust my compensation at any time with or without notice or without cause due to business necessity at its sole discretion.
Employer and Employee further agree that this at-will employment policy cannot be amended, modified or altered in any way by
oral statements or in any other way, and can only be altered by written amendment signed by the Executive Director of the Cal Poly
Corporation.
**For non-student applicants – I understand that Cal Poly Corporation may require my consent to a background check in connection
to my employment.
SIGNATURE:
J:\HUMAN RESOURCES\USR\WP\FORMS\STUDENT-INTERMITTENT APPLICATION.DOC
DATE:
Rev: Sep-12