The Diversity Programs Office Undergraduate Assistant Application

The Diversity Programs Office Undergraduate Assistant Application

Personal Data

Last Name: ______First Name: ______Middle Initial: ______

Social Security #: _____ -_____-_____Date of Birth: ______Gender: M / F

Local Address (Campus)Permanent (Parent’s) Address

Street Address: ______Street Address: ______

City: ______City: ______

State: ______Zip: ______State: ______Zip: ______

Phone: (______) ______Phone: (______)______

Race/Ethnicity (Please check all that apply)

__ African (Black) American__ Asian American

__ Mexican American (Chicano)__ Native American

__ Puerto Rican__ White, not Hispanic

__ Other Hispanic__ Other (Specify) ______

Citizenship:US CitizenPermanent ResidentNon-Resident Alien

Academic Information

Major: ______Advisor: ______

GPA (Cumulative) ______Previous work experience? Y / N

Typing WPM

EMPLOYMENT HISTORY

List your record of employment beginning with your present or most recent position.

Dates
From To / Name and Address of Employer / Position / Supervisor’s Name
and Title / Reason for
Leaving

Describe the work you did:

______

______

EMPLOYMENT HISTORY (continued)

Dates
From To / Name and Address of Employer / Position / Supervisor’s Name
and Title / Reason for
Leaving

Describe the work you did:

______

______

______

Dates
From To / Name and Address of Employer / Position / Supervisor’s Name
and Title / Reason for
Leaving

Describe the work you did:

______

______

______

May we contact the employers listed above? Yes No If not, indicate which one(s) you do not wish us to contact.

______

THREE (3) REFERENCES: ______

______

______

THIS AUTHORIZATION PAGE WILL NEED YOUR

HANDWRITTEN

SIGNATURE AND DATE

I authorize the University to contact each former employer, firm or corporation. I authorize any of these persons to give all information concerning work-related items and I release all parties from liability for any damage that may result from furnishing same to you.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed; falsified statements on this application shall be grounds for dismissal.

I also understand that if accepted by the University, my employment is voluntarily entered into and I am free to resign at any time. Similarly, the University is free to conclude my employment at any time. I further recognize that this application is not a contract and cannot create a contract.

The application deadline is April 10, 2015 at 5:00pm andall application materials (Application, Resume, and Writing Sample) must be received by the:

Diversity Programs Office

KansasStateUniversity

139 Waters Hall

Manhattan, KS66506-1103

______

Applicant’s SignatureDate

DO NOT WRITE IN THES SPACE BELOW

Interview by:______Date:______

Hired: Yes______No ______Position______Salary/Wage:______

Dept. ______Date Reporting to Work ______

Year in School: SO JR SR Expected Graduation Date : (mo/yr) ______/______

Plans after Graduation: GradSchool LawSchool Med.School Other Professional School Obtain Employment

Application must be received by the College of Agriculture Diversity Programs Office, Kansas State University, 139 Waters Hall, Manhattan, KS 66506-1103 by April 10, 2015 by 5:00pm.