MT. San Jacinto College: College Mentor Application Date Application Received:

Transcription

1 MT. San Jacinto College: College Mentor Application Date Application Received: Last Name (Legal Name) First Name M.I. Other Names Used Address City State, Zip Code Date of Birth Home Telephone Cell/Message Telephone Do you have a valid CA driver s license? Yes Number: Social Security Number: Are you willing to Will you attend a MANDATORY Are you willing to work an occasional weekend? work Monday-Friday from 8am-5pm? seminar every Friday from 12PM- 2:00 PM? Yes MSJC Student ID #: Yes Yes Have you ever been employed by MSJC? Yes If yes, list position, department, and dates: Have you ever been a mentor? Yes If yes, when? Have you ever been convicted or pleaded guilty to felony? A conviction is not necessarily disqualifying. Each case will be evaluated on its own merits and its applicability to the position. Yes (List circumstances, places and dates of conviction) Do you require any special accommodations for: (a) The interview? (b) To perform the duties of the job as you presently understand them? Yes (Explain) Yes (Explain) Education Circle highest grade completed: College: Name of School Location Diploma, GED, Degree or Certificate? High School (GED) Major Minor Trade/Vocational School College/University

2 Certificates: 2 List courses/ training programs you have completed that relate to this job: (Example: Psychology 101) Write on last page if extra sheet is needed Are you currently enrolled in 6 units or more at MSJC? Yes If yes, how many units are you currently enrolled in? Do you agree to provide a copy of your transcripts to the Student Life Coordinator to verify your GPA and college units? Yes Initial Here: Do you have any computer training and/or experience? Yes If no, are you willing to learn? Yes List software for which you have a working knowledge: What special qualifications, skills, or experience interests would you bring to this position? (Example: Bilingual) Are you a student in: Are you eligible for Financial Aid? Yes EOPS / CARE DSPS Other All prospective College Mentors must apply for FAFSA regardless of eligibility What do you hope to learn as a mentor? Are there any circumstances that you perceive would limit you in this position? (i.e. time constraints, family responsibilities, etc.)

3 3 Each reference must complete the attached reference form. Make addition copies if needed. REFERENCES 1. Name/Title: 3. Name/Title: Company/School: Telephone Number: Relationship: Company/School: Telephone Number: Relationship: 2. Name/Title: Company/School: Telephone Number: Relationship: EMPLOYMENT RECORD COMPLETE IN FULL List the most recent experience FIRST- Include all U.S. Armed Services, Volunteer Work, and Work Study Positions Dates (Mo/Yr) From To Total Yrs/Mo Organization name and address Position Title Salary. of hrs/week Your Immediate Supervisor Reason for leaving: Telephone Number Duties/Details: Dates (Mo/Yr) From To Total Yrs/Mo Organization name and address Position Title Salary. of hrs/week Your Immediate Supervisor Reason for leaving: Telephone Number Duties/Details:

4 4 Dates (Mo/Yr) From To Total Yrs/Mo Organization name and address Position Title Salary. of hrs/week Your Immediate Supervisor Reason for leaving: Telephone Number Duties/Details: Are you presently employed? May we contact your employer? May we contact your former employer(s)? I hereby certify that all statements on this application are true and complete to the best of my knowledge and belief. If employed, I understand that any falsification of this record or failure to disclose fully the information requested may be considered cause for termination. Signature Date

5 5 References Reference to complete this part. Please keep responses to this sheet: Reference Name: Daytime Telephone Number How long and in what capacity have you known/worked with this student? Have you observed this student being a leader among his/her peers? If so, how? College Mentors take an active role in the Mt. San Jacinto College recruitment activities. They also are involved with orientations, Student Activities, and other campus-wide events. What skills and abilities does this student have that would make him/her a successful College Mentor? How well does this student take direction and/or feedback? Do you have any examples? Do you have any other comments about this student that would help us make a decision about hiring him/her?

6 6 PLEASE MARK THE DAYS AND HOURS THAT YOU ARE AVAILABLE TO WORK. Time Monday Tuesday Wednesday Thursday Friday 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM NOON 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM Are you willing to work occasional Saturdays or Sundays if necessary? Yes