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Student Employment Application

Residential and Student Service Programs (RSSP)

PERSONAL DATA – please type or print Name

Work Study?

Campus Address

Campus Phone #

Home Address

Home/Cell Phone #

Position applied for

E-mail

Do you have a valid driver’s license? Are you currently employed by Cal?

yes ‰

no ‰

yes ‰

Department

If yes, how many hours per week?

yes ‰ Unit

Position

no ‰ Dates

Do you have any relatives employed by RSSP?

yes ‰

no ‰

Name

Relationship

Can you work weekends?

yes ‰

no ‰

Can you work 40 hours per week during summer and breaks?

yes ‰

Summarize your qualifications, background, and any special skills:

REFERENCES—List two references who we may contact: Name

Type of reference:

Title/Relationship

Phone #

Title/Relationship

Phone #

‰ Personal ‰ Employer Name

no ‰

no ‰

Have you ever been employed by RSSP? Position

yes ‰

Type of reference:

‰ Personal ‰ Employer

no ‰


EMPLOYMENT RECORD – List current or most recent first. Include any volunteer work. Dates/Salary Information FROM TO Mo. Yr. Mo. Yr. Hours/week

Employer Firm Name and Address

Your Job Title and Duties

Salary

Name of Your Supervisor Supervisor's Phone Number

Reason for Leaving

Dates/Salary Information FROM TO Mo. Yr. Mo. Yr.

Employer Firm Name and Address

Hours/week

Your Job Title and Duties

Salary

Name of Your Supervisor Supervisor's Phone Number

Reason for Leaving

Dates/Salary Information FROM TO Mo. Yr. Mo. Yr.

Employer Firm Name and Address

Hours/week

Your Job Title and Duties

Salary

Name of Your Supervisor Supervisor's Phone Number

Reason for Leaving

The position you are applying for may be subject to a background check. If a background check is required, you will be asked to sign a release before any checks are conducted. All of the information I have provided here is true and complete to the best of my knowledge .I understand that upon hire I must furnish proof of identity and employment eligibility in accordance with federal law. I further understand that the Berkeley Campus may make any necessary investigations into my personal history as it relates to my employment, through any investigative means of the Campus' choice. I authorize the University of California to verify the information on any materials that I have submitted as part of the application process and to contact my references if I become a final candidate for the position. I am certifying that the information I have submitted is subject to verification and that if I am hired, any misrepresentations, falsifications, or omission may be grounds for termination of my employment with the University. I understand that employment may be subject to appropriate medical clearance. Signature

Date

Nondiscrimination and Affirmative Action Policy Statement for University of California Publications Regarding Employment Practices The University of California prohibits discrimination against or harassment of any person employed by or seeking employment with the University on the basis of race, color, national origin, religion, sex, gender identity, pregnancy [1], physical or mental disability, medical condition (cancer-related or genetic characteristics), ancestry, marital status, age, sexual orientation, citizenship, or service in the uniformed services (as defined by the Uniformed Services Employment and Reemployment Rights Act of 1994). [2] University policy also prohibits retaliation against any employee or person seeking employment for bringing a complaint of discrimination or harassment pursuant to this policy, or against a person who assists someone with a complaint of discrimination or harassment, or who participates in any manner in an investigation or resolution of a complaint of discrimination or harassment. The University of California is an affirmative action/equal opportunity employer. The University undertakes affirmative action to assure equal employment opportunity for minorities and women, for persons with disabilities, and for covered veterans. [3] University policy is intended to be consistent with the provisions of applicable State and Federal laws. Inquiries regarding the University's equal employment opportunity policies go to the "Resolving Discrimination Issues" section of the Campus Climate and Compliance Office website at http://ccac.berkeley.edu/resolving.shtml. [1] Pregnancy includes pregnancy, childbirth, and medical conditions related to pregnancy or childbirth. [2] Service in the uniformed services includes membership, application for membership, performance of service, application for service, or obligation for service in the uniformed services. [3] Covered veterans includes veterans with disabilities, recently separated veterans, Vietnam era veterans, veterans who served on active duty in the U. S. Military, Ground, Naval or Air Service during a war or in a campaign or expedition for which a campaign badge has been authorized, or Armed Forces service medal veterans. 7/09


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