c:\users\hclieu\documents\sitetransfer\hr\on-campus jrf - june 2014.doc
BOT Date ______________ JOB REFERRAL FORM FWS Award __________
ON-CAMPUS STUDENT EMPLOYMENT [ ] Fall [ ] Spring
K # ____________________ BOARD AGENDA ITEM __________________
Financial Aid Signature
Please return COMPLETED form in triplicate to the Student Employment Office.
This Student may not begin working until the Supervisor receives a HOT PINK FORM from the Student Employment Office.
PLEASE PRINT THE FOLLOWING INFORMATION: Email Address: _______________________________
NAME: ____________________________________________________________ PHONE: __________________
Last First MI (home)
ADDRESS: _________________________________________________________ PHONE: __________________
Number & Street Name (cell)
______________________________________________________________________________________________
City State Zip
Status (choose one): [ ] US Citizen [ ] Permanent Resident [ ] Temporary Resident
[ ] Refugee/Asylee [ ] Student Visa (F1 or M1 Visa) [ ] NRA/Other
DEPT: ________________________________ SUPV: (print)_____________________________ EXT: ___________
Program Administrator (if applicable) (print): __________________________________________________________
CHOOSE ONE:
[ ] NEW STUDENT WORKER [ ] RETURNING [ ] ADDITIONAL JOB
TERM: (
circle one) FALL / SPRING / SUMMER BEGINNING DATE OF ASSIGNMENT: ________________
General type of work: (circle one)
Classroom Lab Clerical Driver DSPS Event Coordinator Facilities Food Service Model/Actor
PE/Athletics Security Tutor/Inst Aide Other: (describe type of work) ______________________________
Student worker level: I II III IV V VI
Student worker pay rate: $9.00 $10.06 $11.12 $12.18 $14.29 $15.35
Change in level and rate? Y / N Effective date of change: ___________________________
Budget number: ______________________________________________________________________
Change in budget number? Y / N Effective date of change: ___________________________
NOTE: On-Campus Student Employees may not work more than 19.5 hours in a week and not more than 175 days or 1000 hours in a
fiscal year. On-Campus Student Employees are temporary, non-classified service employees employed to perform a service in the District,
upon completion of which the services required will not be extended or needed on a continuing basis. They are to be hired on temporary
basis only to provide additional services for a short-term project or assignment.
APPROVAL SIGNATURES
Supervisor: ____________________________________________________________________ ______________
Date
Dean/V.P./Reviewing Manager: ___________________________________________________ ______________
Date
Human Resources: ______________________________________________________________ ______________
Date
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