Position applying for: ______ Date:

Name:________________________________________________________

Dorm Extension: Suite Number: ______

Classification: ________________________ GPA: ____________________

Major: _________________________ Specialization: __________________

Which subjects can you tutor?

__________________________________________________________________________________________________________________________

Pertinent prior experience:

__________________________________________________________________________________________________________________________

Are you work-study eligible? ______________________________________

Number of hours you can work: ___________________________________

Are you willing to receive training? _________________________________

Are there other obligations that may interfere with your work schedule? If yes, please list them:

__________________________________________________________________________________________________________________________

Please submit the following information:

References (Include name, address, and phone number)

Transcript (May be obtained from the registrar’s office)

Writing sample (this may be a previous assignment from a course)

The above stated information is accurate to the best of my ability.

Signature________________________________ Date _________________