CORNELL UNIVERSITY
STUDENT EMPLOYEE APPLICATION
PERSONAL INFORMATION
NAME: ___________________________________ CUID #: _____________________ NETID:_______
LOCAL ADDRESS: _______________________________________ LOCAL PHONE: ______________
EMERGENCY CONTACT- Name: _________________________ Phone: ( ) ________________
- Address: ______________________________________________________
___U.S. CITIZEN OR PERMANENT RESIDENT
___FOREIGN NATIONAL PLEASE NOTE VISA STATUS: ___FI ___J1 Other_________
COLLEGE:________________________________ EXPECTED GRADUATION DATE: _____________
ARE YOU CURRENTLY: Registered Full-time and Attending Classes __Yes __No
FWS Eligible: __Yes __No
Tradition Fellow: __Yes __No
COSEP __Yes __No
ARE YOU CURRENTLY WORKING? __No __Yes Are you working at Cornell? __ No __Yes
JOB INFORMATION…please identify the position to which you are applying
Position Title: _________________________________________________________________________
Department: _________________________________________________________________________
Contact Person: _________________________________________________________________________
EXPECTED SCHEDULE OF AVAILABILITY…list all available work hours, including
weekends and evenings
Monday ________________________ Friday ________________________
Tuesday ________________________
Wednesday ________________________ Saturday ________________________
Thursday ________________________ Sunday ________________________
LIST RELEVANT EXPERIENCE, SKILLS, AND COURSEWORK…or further
information that will support your application for the above position. Include relevant courses,
specific computer skills, customer service skills, etc.)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
OVER
EMPLOYMENT HISTORY…list most recent, relevant employment first
Employer:________________________________________________ Dates Employed: ______________
Supervisor’s Name:________________________________________ Phone #:_____________________
Employer’s Address:_____________________________________________________________________
Position Held/Description of Duties: ________________________________________________________
______________________________________________________________________________________
Employer:________________________________________________ Dates Employed: ______________
Supervisor’s Name:________________________________________ Phone #:_____________________
Employer’s Address:_____________________________________________________________________
Position Held/Description of Duties: ________________________________________________________
______________________________________________________________________________________
Employer:________________________________________________ Dates Employed: ______________
Supervisor’s Name:________________________________________ Phone #:_____________________
Employer’s Address:_____________________________________________________________________
Position Held/Description of Duties: ________________________________________________________
______________________________________________________________________________________
REFERENCES…list three contacts
1. Contact Name: ______________________________________________________________________
Relationship: __________________________ Area Code/Phone #: _________________________
2. Contact Name: ______________________________________________________________________
Relationship: __________________________ Area Code/Phone #: _________________________
3. Contact Name: ______________________________________________________________________
Relationship: __________________________ Area Code/Phone #: _________________________
READ, COMPLETE, AND SIGN…
Have you ever been referred to the Judicial Administrator for alleged violation(s) of the Campus
Code of Conduct? No__ Yes__
If you answered yes, please give dates (including currently pending matters), describe the
circumstances, and indicate how the case was resolved.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I hereby authorize the Judicial Administrator and other employment references to release to the department to
which I am applying for employment any and all information that, in the Judicial Administrator’s opinion, may
be relevant to my duties and responsibilities as a student employee. This release remains in effect unless and
until revoked in writing, or until my date of graduation from Cornell, whichever occurs first. I certify that the
information I have given is true, and understand that misrepresentation or omission of facts called for in this
form is cause for termination of employment without notice.
Signature: __________________________________________ Date: ___________________________
DEPARTMENT USE ONLY
Job Offer: __ No __ Yes Start date: _______________________ Wage: _______________
Position: _____________________________________________ Supervisor: ___________________________________________
I-9 Employment Eligibility Verification completed: __No __Yes Date:___________________________________________
Rev. 7/25/08