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
LAST NAME
FIRST
MID. INITIAL
ADDRESS – NUMBER & STREET
HOME PHONE
CITY/STATE/ZIP
(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

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: 06/2014

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