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Upward Bound Residence Hall Staff Application

General Information
*Name: 
*SSN: 
*Student ID#: 
*Address: 
*City: 
*State:
*Zip Code: 
*Phone Number: 
*E-Mail Address: 
*Current Year:
*Major:
*GPA: 
Job Experience
Please list any past or current employment, starting with the most recent.
Most Recent Job:

Add Employment History:

Add Employment History:
Extracurricular Activities / Organizations

Please list any extracurricular activities you have been involved with while in college and briefly describe your involvement with that organization. Please use a separate sheet if necessary.

Organization / Activity 
Involvement 
Organization / Activity 
Involvement 
Organization / Activity 
Involvement 
References

Please list two professional references that we may contact.

*Name: 
*Title / Position: 
*Address: 
*Phone: 
*Company or Institution: 

*Name: 
*Title / Position: 
*Address: 
*Phone: 
*Company or Institution:  
Signature

I hereby attest that the above listed information is true and accurate to the best of my knowledge. I understand that if I am employed, any information withheld, either knowingly or fraudulently represented, could result in termination form the MSSU Upward Bound program. I understand that a background check will be conducted and agree to this as part of the hiring process.

SID
PIN