Office of Outreach

2014Summer Academy Counselor/Instructor Application

Section A

Applicant Information (please use current/msu address, etc.)

Last Name / First / M.I.
Street Address / Apartment/Unit #
City / State / ZIP
Phone / E-mail Address
Date Available / MSU net ID
Are you a citizen of the United States? / YES / NO / If no, are you authorized to work in the U.S.? / YES / NO
Have you ever worked for this office? / YES / NO / If so, when?
Are you eligible for student worker employment? / YES / NO / If no, explain

Education

High School / Address
From / To
College (other than MSU) / Address
From / To / Cum GPA / Major
Minor
MSU Department / Major
Cum GPA / Minor

References:

Please list three references.
Full Name / Relationship
Company / Phone / ( )
Address
Full Name / Relationship
Company / Phone / ( )
Address
Full Name / Relationship
Company / Phone / ( )
Address

Military Service

Branch / From / To
Rank at Discharge / Type of Discharge
If other than honorable, explain

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview
may result in my release.
Signature / Date

To complete your application, please submit three letters of reference using the attached form. At least one letter must be completed by a University Professor and one from a former employer. Applications cannot be considered until all three letters are received. All applications are due to Eric Heiselt in the Outreach Office (McCain 200) by April 15, 2014.

Bagley College of Engineering, Office of Outreach

Attn: Eric Heiselt

200 McCain Hall; Mailstop 9544

Mississippi State, Mississippi 39762

Reference Evaluation Form

Part I

(To be completed by Applicant)

Applicant Name ______MSU Net ID ______

Position Desired___K-12 Summer Academy Counselor______

Please complete the evaluation found in Part II below based on your knowledge of my background and mail to the address above. I hereby waive my right to access of this confidential recommendation obtained for my application for employment.

Signature ______Date ______

Part II

(To be completed by Evaluator)

Command of English Language / Extremely Fluent/Precise / Correct in Usage / Usually Correct / Frequently Incorrect
Academic Acuity / Outstanding/Innovative and Quick to Learn / Adequate in Ability to Learn / Limited in Learning / Insufficient for Success
Professional Attitude / Always Professional / Professional / Usually Professional / Frequently Unprofessional
Use of Sound Judgment / Exceptional in Judgment / Good in Common Sense / Fair in Judgment / Unreliable in Judgment
Reliability / Always Dependable / Usually Dependable / Fairly Reliable / Inconsistently reliable
Character / Outstanding / Above Average / Average / Fair
Relationships with Others / Superior / Above Average / Satisfactory / Frequently Annoying
Cooperation / Outstanding / Cooperative / Usually Cooperative / Uncooperative
Leadership Qualities / Outstanding / Present but Undeveloped / Very Limited / Lacks skills

Please comment on the following using the back of the form if additional space is needed:

Would you recommend the applicant as a mentor/counselor for middle school and high school students?

If no, please explain: ______

If a previous employer, would you re-employ?

If no, please explain: ______

General Comments: ______

______

Name (please print): ______Position: ______

Signature: ______Date: ______

Contact Address: ______

Contact Phone Number: ______