KEENE STATE COLLEGE
DEPARTMENT OF CAMPUS SAFETY
229 MAIN ST., KEENE, NH 03435
STUDENT EMPLOYMENT APPLICATION - Please Print
Personal and Contact Information
Last Name: ____________________________ First Name: __________________________MI: ______
Cell Number: ( ) ___________ E-Mail: _______________Campus Address:__________________
Home Address: _______________________________________________________________________
City: ______________________State: _____Zip: __________
Student ID # _____________Major: __________________________Year of Graduation:____________
US Citizen: Yes No If No, please list VISA type:____________________
Circle Positions of Interest (not all positions may be available depending on current staffing)
Parking Enforcement Parking Office Switchboard
Work Study: Yes No
Please list hours you are available/interested in working:
DAY
HOURS
DAY
HOURS
Saturday
Wednesday
Sunday
Thursday
Monday
Friday
Tuesday
Date Available to Start: _______________________
Disclosure Information
In answering the following questions, you may omit any information or answer “no record” with regard
to conviction for which there is a sealed record on file.
Have you ever been convicted of a crime? Yes No
Provide the court and date of conviction, the offense and the name under which you were
convicted, if different from the name listed on this application.
Have you ever been found responsible for a conduct violation at KSC or any other school? Yes No
Have you ever received a parking violation at KSC? Yes No
Provide the type of violation, the date and the sanction/fine.
KEENE STATE COLLEGE
DEPARTMENT OF CAMPUS SAFETY
229 MAIN ST., KEENE, NH 03435
Employment History Please list most recent position first
Company/Organization: _______________________________________________________________
Address: _______________________________________ City: ____________________State: ______
Supervisor Name and Position: _____________________________Telephone #: _________________
Position Title: ___________________________________Responsibilities:_______________________
_______________________________________________________________________
Dates of Employment: ____________________________________ Salary: ______________________
Reason for leaving: ___________________________________________________________________
Company/Organization: _______________________________________________________________
Address: _______________________________________ City: ____________________State: ______
Supervisor Name and Position: _____________________________Telephone #: _________________
Position Title: ___________________________________Responsibilities:_______________________
_______________________________________________________________________
Dates of Employment: ____________________________________ Salary: ______________________
Reason for leaving: ___________________________________________________________________
Personal References Contact information for individuals you have known 2 years or more (excluding family)
Name: _________________________________________________ Telephone #: _________________
Relationship to applicant: __________________________________ Email: ______________________
How long have you known this person? _______________________
Name: _________________________________________________ Telephone #: _________________
Relationship to applicant: __________________________________ Email: ______________________
How long have you known this person? _______________________
Emergency Contact
Name: _________________________________________________ Telephone #: _________________
Relationship: _________________________
Statement of Understanding
I affirm that the information provided herein is true and accurate to the best of my knowledge.
I understand that my employment is contingent upon a successful background investigation.
I understand that I may be subject to termination should information come to light during the
background investigation that may conflict with my ability to perform my job responsibilities.
I further understand that any false statement on this application is sufficient reason for dismissal.
Signature: _______________________________________________ Date: ______________________
DO NOT WRITE BELOW THIS LINE
Date Received: _________________ By: ____________________ Date Reviewed: __________________By: ____________________
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