Fillable STUDENT EMPLOYMENT APPLICATION (Federal Work Study Program) (Southern University at Shreveport)

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STUDENT EMPLOYMENT APPLICATION (Federal Work Study Program) (Southern University at Shreveport)

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Southern University at Shreveport does not discriminate on the basis of race, color, national origin, gender, age, disability or any other
protected class. Title IX Coordinator: Dr. Tuesday W. Mahoney, Johnny L. Vance, Jr. Student Activity Center, Room 208, (318) 670-9201.
Section 504 Coordinator: Ms. Jerushka Ellis, Health & Physical Education Complex, Room 314, (318) 670-9367.
Revised 05/2018
L.C
. Barnes Administration
Bldg., Room A-43
3050 Martin Luther King, Jr Dr.
Shreveport, LA 71107
Phone:(318)670-9221
Fax: (318) 670-6313
Email: financialaid@susla.edu
Office of Financial Aid & Scholarships
STUDENT EMPLOYMENT APPLICATION
(Federal Work Study Program)
**CHECK ALL SEMESTERS OF INTEREST**
Fall _____ Spring _____ Summer _____
ARE YOU INTERESTED IN AN OFF-CAMPUS JOB? YES NO
PERSONAL INFORMATION
Application Date:
Student Banner Number:
Name:
Social Security Number:
Street Address:
City, State, Zip Code:
Telephone Number:
Email Address:
Emergency Contact: Relationship
----------------------------------------------------------------------------- -------------------------------------------------------------
Phone Number: _________________________________
STUDENT STATUS
Academic Major:
__________________________
# of Credits Enrolled:
__________
Have you been offered Federal Work Study?
YES
NO
Have you accepted Federal Work Study?
YES
NO
Does SUSLA currently employ any of your relatives? YES NO
If yes: Name___________________________ Relationship __________________ Department
______________
Campus Employment
Do you, or have you, worked anywhere on
campus? YES NO
If yes: Department____________________________ Semester Employed _________/__________
ex: Fall / 2017
CONFIDENTIALITY AGREEMENT
At Southern University at Shreveport, I understand that I may have access to files containing information, which
includes but is not limited to confidentiality issues regarding employees and students. I understand that I have
access to this information only because I am employed in this Department/Work Area. I agree that I shall not
disclose this information to anyone outside of this Department/Work Area.
I agree to be bound by this Confidentiality Agreement and take all reasonable, necessary and appropriate steps to
safeguard private data from disclosure to anyone except as permitted under the Agreement. I understand that
violation of this agreement will subject me to disciplinary action affecting my employment at Southern University at
Shreveport as a student worker.
Southern University at Shreveport does not discriminate on the basis of race, color, national origin, gender, age, disability or any other
protected class. Title IX Coordinator: Dr. Tuesday W. Mahoney, Johnny L. Vance, Jr. Student Activity Center, Room 208, (318) 670-9201.
Section 504 Coordinator: Ms. Jerushka Ellis, Health & Physical Education Complex, Room 314, (318) 670-9367.
Revised 05/2018
Supervisor request
If someone is requesting you (the student) to work in their department, please have them
complete this section. Otherwise, leave this section blank.
Requestor’s Signature: _________________________________________________________
As a Southern University at Shreveport student, I understand that failure to attend class and/or failure to maintain
proper work ethics will result in my immediate dismissal from the program if hired. I understand that this is a part-
time job. No student should work during scheduled class periods. A student may work up to twenty (20) hours
per week while classes are in session. Federal Work-Study students may work up to thirty-five (35) hours per
week between terms and during Spring Break if the employer has sufficient work and adequate budget. I also
understand I cannot exceed my maximum allowable earnings for the work-study assignment period. As a student
employee, I will abide by all rules and regulations set forth by the University, Work Study Coordinator and the
assigned Supervisor.
Student Name (please print)
Student ID #
Date
Student Signature
_____________________________________________________________________________
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STUDENT EMPLOYMENT APPLICATION (Federal Work Study Program) (Southern University at Shreveport)

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Completed 26 July 2020

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