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Student Service Scholarship Application

Catholic Campus Center at Washburn University
1633 SW Jewell
Topeka, KS 66044

Student Application for Student Service Scholarship Position
Date of application: ___________________

Contact Information

                                                               _____________                  ________                                              Last Name                                           First Name                            Middle Name                                       Suffix

__________________________________________________________________________
Present Street Address

__________________________________________________________________________
City                                                                     State                                                     Zip

___________________________________
E- mail Address                                                                                Social Security Number

______________________________                              ____________________________________
Primary Phone                                                         Mobile Phone
______________________________
WIN #

Are you a Washburn University Student? ____YES ____NO
If yes, part-time student______ full-time student______

What is your last semester GPA?______

Are you a registered member of the Catholic Campus Center? ____YES ____NO

Do you have phone experience ? ____YES ____NO If yes, where and when?___________

Do you have clerical experience ? ____YES ____NO If yes, where and when?___________

Do you have web experience ? ____YES ____NO If yes, where and when?___________

Availability

DAY OF WEEK                                             Time Available to Work
Tuesday _____                                                _______ to _______
Wednesday_____                                                          _______ to _______
Thursday _____                                              _______ to _______
Friday _____                                                  _______ to _______

Education

School Attended	Name of School (include complete address)	Did you Graduate?	Circle last year completed	Credits/ Degree	Major/Minor
High School			9 10 11 12
Undergraduate School			1 2 3 4
Graduate School
Graduate School area(s) of concentration:

References
Give name, address and telephone number of references who are not related to you and are not previous employers. (Use additional sheet if needed.)

1.
     Name                          Address                                       Phone
2.
     Name                          Address                                       Phone
3.
     Name                          Address                                       Phone

Employment Experience

1. Job Title                     _______________              From           ____ (Mo./Yr.) To___________(Mo./Yr.)
                                                                        (Dates of Employment)
______________________________________________________________________________
Name of Employer                                                         Address of Employer
_____________________________________________________________________________
Name of Supervisor                                         Title of Supervisor                          Phone No. of Supervisor
______________________________________________________________________________
Reason for leaving                             ______________________________________________________________________________
Description of Duties
__________________________________________________________________________________________
Beginning Salary                                                                                          Ending Salary

2. Job Title                     _______________              From           ____ (Mo./Yr.) To___________(Mo./Yr.)
                                                                        (Dates of Employment)
______________________________________________________________________________
Name of Employer                                                         Address of Employer
_____________________________________________________________________________
Name of Supervisor                                         Title of Supervisor                          Phone No. of Supervisor
______________________________________________________________________________
Reason for leaving                             ______________________________________________________________________________
Description of Duties
__________________________________________________________________________________________
Beginning Salary                                                                                          Ending Salary