Proposed Class and Work Schedule
with Regard to Application for Student Employment

Re:    Application for Student Employment (check one):
    ___ a. Undergraduate Student Worker
    ___ b. Masters Degree Student - Graduate Assistant
    ___ c. PhD Student - Graduate Assistant

Date:  __________________

Name (Print): _________________________________  S.S. #: ____________________

Requested Work Term (check one):
___ Summer Session 1    ___ Summer Session 2    ___ Fall    ___ Spring

Hours that you would like to work each week:
___ 10 hours
___ 15 hours
___ 20 hours
___ Other: ______________

Instructions: Please indicate in the chart below when you are attending class and proposing to work.

                                        Day:
Time:        Mon            Tue            Wed            Thur            Fri
8

9

10

11

12

1

2

3

4

5

State law requires that you be informed of the following: (1) you are entitled to request to be informed about the information about yourself collected by the use of this form (with a few exceptions as provided by law); (2) you are entitled to receive and review that information; and (3) you are entitled to have the information corrected at no charge to you.