Cal Poly Student Employment Application

Please submit completed applications to the College Reading Skills Program at the Learning Resource Center
Bldg 15, Rm 4.

CAL POLY STUDENT EMPLOYMENT APPLICATION

	Please complete the entire application form, by providing all information requested including salary history, employment dates and a summary of duties performed for each job listed. A resume may be attached, but will be considered as supplemental information only and not as a replacement for information requested on the application.
	3801 West Temple Avenue, Pomona, California 91768-4038 Human Resource Department, Building 55 – (909) 869-2953 or 869-4378 Job Line: (909) 869-4752 Fax: (909) 869-3716 Web-Page: www.foundation.csupomona.edu

The Cal Poly Pomona Foundation, Inc., is committed to a diverse workforce. It is an Affirmative Action Employer and it is an Equal Opportunity Employer.

POSITION DESIRED			SOCIAL SECURITY#
LAST NAME	FIRST	MID. INITIAL	UNIVERSITY ISSUED PIN# (if applicable)
ADDRESS – NUMBER & STREET			HOME PHONE
CITY/STATE/ZIP		DRIVER'S LICENSE NO.	STATE OF ISSUE	EXPIRATION DATE (mm/dd/yy)
(If you are offered employment and your position includes driving a Foundation vehicle, your driving record will be checked.)

EDUCATION

ACADEMIC STATUS: FRESHMAN SOPHOMORE JUNIOR SENIOR OTHER
CURRENT G.P.A.	MAJOR				EXPECTED YEAR OF GRADUATION

WORK AVAILABILITY SCHEDULE

PLEASE “X” THE DAYS AND HOURS YOU ARE AVAILABLE TO WORK

TIME	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM

QUARTER: FALL WINTER SPRING SUMMER

EMPLOYMENT RECORD (Please list present and most recent experience)

DATES (mo/yr)		Firm Name and Address	Position Title	May we contact your current employer? Yes No Supervisor Phone No.
From	To
Ending Salary No. Hrs. Per Week		Reason for Leaving
		Duties

DATES (mo/yr)		Firm Name and Address	Position Title	May we contact your current employer? Yes No Supervisor Phone No.
From	To
Ending Salary No. Hrs. Per Week		Reason for Leaving
		Duties

PROFESSIONAL REFERENCES
(Please list former Supervisors and/or Associates who are acquainted with your professional qualifications and who may be contacted for reference).

NAME	COMPANY/ADDRESS	TITLE	PROFESSIONAL RELATIONSHIP	PHONE

EMERGENCY INFORMATION (Please list an individual who should be contacted in the event of an emergency.)

NAME	ADDRESS	RELATIONSHIP	PHONE

SIGNATURE AND CERTIFICATION

If an offer of employment is made, can you provide proof of your identity and submit documentation of your legal right to work in the United States? YES NO
Have you ever been convicted of a Felony? YES NO	(If yes, please explain)

I hereby certify that the information contained in this application and all supplemental support documents is accurate and truthful to the best of my knowledge and belief. I understand the misstatement or omission of pertinent facts or information may disqualify me from employment consideration with Cal Poly Pomona Foundation, Inc. and if hired, may be grounds for dismissal. I authorize Cal Poly Pomona foundation, Inc. to investigate any information contained in this application and support documents in consideration for employment. I authorize my former employers or persons named above to give any information they may have regarding my employment, whether on record or not. I hereby release said companies, schools or persons from all liability for any damage whatsoever for issusing this information. If hired I will comply with all orders, rules and regulations of the Cal Poly Pomona Foundation, Inc. I understand that my employment is At Will and can be terminated with or without prior cause or notice at any time at the option of myself or the Foundation. My signature is evidence that I have read and agree with the above statements.

Applicant's Siganture _______________________________________________

Date (mm/dd/yy)

Revised: 08/2002

CONTINUE to print the Affirmative Action Applicant Data Form

CRSP Home