Student Application Form

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Department of Public Safety
Application for Student Employment

- Section One - Contact Information (A * denotes a required entry):

Name (Last, First, M.I.): *
Email Address:
Campus / Local Address: *
Home Address: *
Home City, State, Zip: *
V.U. / Banner / Novasis ID #: *
Campus / Local Phone Number: *
Home Phone Number: *
Emergency Contact Information: *

- Section Two - Status:

Your Student Year (Sophomore, Junior, Senior): *

Citizen Status (U.S., Resident Alien, Other - specify): *

Do you have a valid driver's license? (Yes / No):
                                                        State:     License Number:

Have you ever been convicted of a Felony? (Yes / No): *
                                 If Yes; provide date, offense, and disposition:


- Section Three - Eperience / Education / Etc.:

List any special skills, education, or training:

Prior Experience:

(You will receive a confirmation page upon successful submission of this form)