Your Information

Student ID #

Local/Virginia Tech Address

Street Address

Phone Number

Virginia Tech E-mail address

Permanent Address

Street

Phone Number

Academic Information

Academic Level Freshman Sophmore Junior Senior Grad. Student

Your Major(s)

Expected Graduation Date

Are you currently a full-time student? Yes No

Current/Past Employment

Have you ever worked at VTSCC? Yes No

Are you currently employed by another VT department? Yes No

If yes, which department(s)?

If yes, how many hours/week?

If you work for another university department, you are limited to a total of 40 hours per week split between the VTSCC and your other university employer.

Prior Work Experience

Please list your two most recent employments, starting with your current or last-held job.

Employer Name

Employer Street Address

Phone Number

Your Job Title

Supervisor’s Name & Title

Equipment Used

Your name, if different from present

Reason for leaving

Please summarize your work and responsibilities

Were you employed full or part-time? Full-time Part-time

Number of hours you worked per week

Employer Name

Employer Street Address

Phone Number

Your Job Title

Supervisor’s Name & Title

Equipment Used

Your name, if different from present

Reason for leaving

Please summarize your work and responsibilities

Were you employed full or part-time? Full-time Part-time

Number of hours you worked per week

References

First Reference Name

Address

Phone Number

Relationship to you

Second Reference Name

Address

Phone Number

Relationship to you

Please tell us any additional information you feel we should know when evaluating your application

Have you been convicted of any violation(s) of law including moving traffic violations or juvenile convictions committed after your fourteenth birthday? Yes No

If yes, please provide a description of the offense, statute or ordinance (if known) date of charge, date of conviction and County, City and State of conviction.

Certification - Each application requires current date and orignal signature—I hereby certify that all entries on both pages and attachments are true and complete, and I agree that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any employment in the service of the commonwealth of virginia. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent to references and former employees and educational institutions listed being contacted regarding this application. I further authorize the commonwealth to rely upon and use, as it sees fit, any information recieved from such contacts. Information contained on this application may be disseminated to other agencies, nongovernmental organizations or systems on a need to know basis for good cause as determined by the agency head or designee.

Applicant Signature (type your full name)

Today’s Date

Which two days between Monday and Thursday would you want to work? Is there a class conflict that would prevent you from working another shift? If so, please explain: