Position Company Dates of
Name Position/Title Address and Phone Number
I hereby authorize Missouri State University to contact additional individuals with respect to this application, except the
following people who should NOT be contacted unless I become a finalist:
1. _______________________________________ 1.
2. _______________________________________ 2. ____________________________________________
ADDITIONAL INFORMATION (Please provide any additional information that you consider
important to your employment as a Graduate Assistant).
I certify that the information in this application is complete and accurate to the best of my knowledge.
Signature Date _______
Missouri State University is a community of people with respect for diversity. The University emphasizes the dignity and equality common to all persons and adheres to a strict
nondiscrimination policy regarding the treatment of individual faculty, staff, and students. In accord with federal law and applicable Missouri statutes, the University
discriminate on the basis of race, color, religion, sex, national origin, ancestry, age, disability, or veteran status in employment or in any program or activity offered or
by the University. In addition, the University does not discriminate on any basis (including, but not limited to, political affiliation and sexual orientation) not related to the
applicable educational requirements for students or the applicable
job requirements for employees.
The University maintains a grievance procedure incorporating due process available to any person who believes he or she has been discriminated against. Missouri State
University is an Equal Opportunity/Affirmative Action employer. Inquiries concerning he grievance procedure, Affirmative Action Plan, or compliance with federal and state
laws and guidelines should be addressed to Jana Estergard, Equal Opportunity Officer, Park Central Office Bldg. 111, 901 South National, Springfield, Missouri 65897,
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