LOCK HAVEN UNIVERSITY OF PENNSYLVANIA GRADUATE ASSISTANTSHIP EMPLOYMENT APPLICATION

Dates Attended

Institution and Location

Degrees, if any

Date Granted

Hours Credit

Sem or Qtr

LOCK HAVEN UNIVERSITY OF PENNSYLVANIA
GRADUATE ASSISTANTSHIP EMPLOYMENT APPLICATION

Name ___________________________________ Social Security Number __________________

Address ___________________________________ Home Phone _________________________

___________________________________ Work Phone _________________________

Graduate Assistantship Position Desired________________________________________________

When Available to Work__________________________________________________________

Do you have any specialized training, skills, qualifications, or licenses?____________________________

___________________________________________________________________________

EDUCATION

Baccalaureate GPA ____________________________ (Graduate Assistantships require a minimum 3.000 GPA in the baccalaureate program.)

PERSONAL

Have you ever been employed by the Commonwealth of Pennsylvania? Yes No If yes, by what Agency?		From Mo. & Yr.	To Mo. & Yr.
Are you a US veteran? Yes No	If yes, were you honorably discharged? Yes No
Are you a US citizen? Yes No	If not, are you legally eligible to accept employment in the US? Yes No

Within the last five years, have you been fired from any job for any reason or have you quit a job after being notified that you would be fired?* Yes No

*Note if you answer yes, on a separate sheet of paper, give all the facts. Show name and address (including zip code) of employer, approximate date, and reasons in each case. Being fired from a position does not mean you cannot be appointed. The nature of the firing and how long ago it occurred are important.

Were you ever convicted of a criminal offense, or have you ever forfeited bond or collateral in connection with a criminal charge?* Yes No

*Omit: minor traffic violations and any offenses committed before your eighteenth birthday which were finally settled in a juvenile court or under a youth offender law. Conviction of a criminal offense is not a bar to employment in all cases. Each case is considered on its merits. If yes, give details on a separate sheet of paper. (Be sure to include your name and social security number on the paper.)

If you are applying for a position which requires a driver's license, do you possess a current Pennsylvania driver's license? Yes No

Do your records appear in any name(s) other than the name listed above? If so, please list name(s).

____________________________________________________________________________

EMPLOYMENT HISTORY (Begin with present, or most recent, employment). Attach additional pages if necessary.

Name and Address of Employer

Dates Employed (Mo. & Yr.)

From To

Reason for Leaving

Title of Your Position

Name of Immediate Supervisor

Area Code Phone Number

Number & Kind of Employees You Supervised

Description of Duties _______________________________________________________________

Name and Address of Employer

Dates Employed (Mo. & Yr.)

From To

Reason for Leaving

Title of Your Position

Name of Immediate Supervisor

Area Code Phone Number

Number & Kind of Employees You Supervised

Description of Duties_______________________________________________________________

Name and Address of Employer

Dates Employed (Mo. & Yr.)

From To

Reason for Leaving

Title of Your Position

Name of Immediate Supervisor

Area Code Phone Number

Number & Kind of Employees You Supervised

Description of Duties _______________________________________________________________

May we contact present/previous employers as references? Yes No
If no, state reason: _________________________________________________________________

REFERENCES

List three persons (at least one of whom is a former or present employer if you are or have been employed) who have knowledge of your work experience and/or education. By listing these, you authorize the University to contact said persons for a reference on your behalf and also authorize them to release information on your behalf.

______________________________________________________________________________________
Name Address Phone

I certify that all of the statements made by me on this form are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I understand that provision of false or misleading statements may subject me to criminal prosecution and may subject me to termination of any employment gained pursuant to this document.

______________________________________________________________________________ Signature of Applicant Date