University of Illinois for Office Use Only

Rev 2/06

University of Illinois For Office Use Only:

Survey Research Laboratory Date received:

Date interviewed:

INTERVIEWER APPLICATION FORM Action:

Champaign-Urbana Office

Instructions: Save this form to your computer and complete it in Microsoft Word, then e-mail it to . You also can print this document, fill it out by hand, and fax it to JOBS@SRL at (217) 244-4408.

(FIRST, MIDDLE, LAST)

Rev 2/06

Home phone:

Cell phone:

Work phone:

E-mail address:

EDUCATION

Please record your education experience below. Begin with your last high school, and list schools or colleges attended after that.

School or College / City, State / Years Attended / Major / Degree/Diploma
to
to
to
to

1a. Are you currently employed? Yes

No® (SKIP TO Q.2)

1b. How many hours per week are you currently working? hrs/wk

2. Have you ever been employed? Yes

No ® (SKIP TO Q.4a)

3. Please list all relevant employment information, beginning with your current or most recent job.

Interviewer application: Champaign-Urbana 2

[1] Employer

Street address

City, State, ZIP

Job description

Dates of employment

Interviewer application: Champaign-Urbana 5

[2] Employer

Street address

City, State, ZIP

Job description

Dates of employment

Interviewer application: Champaign-Urbana 5

[3] Employer

Street address

City, State, ZIP

Job description

Dates of employment

Interviewer application: Champaign-Urbana 4

4a. Are you currently enrolled in an undergraduate or graduate program?

Yes

No ® (SKIP TO Q.5a)

Interviewer application: Champaign-Urbana 4

4b. At what school?

Interviewer application: Champaign-Urbana 4

4c. How many credit hours are you currently taking? hrs/wk

4d. When do you plan to graduate/get your degree? /

MONTH/YEAR

5a. Do you have any survey research interviewing experience?

Yes

No ® (SKIP TO Q.6)

5b. Have you had experience with . . .

Yes No

1) Telephone interviewing?

2) Face-to-face interviewing?

3) Other types of interviewing? (PLEASE SPECIFY TYPES)

5c. Please describe these survey interviewing experiences if not already listed under employment. (INCLUDE EMPLOYER AND DATES)

6. Please list any other experiences (workshops, conferences, work, hobbies, etc.) you may have had that might be relevant to interviewing or survey research.

7. Are you usually available for . . .

Yes No

1) Daytime interviewing?

2) Evening interviewing?

3) Weekend interviewing?

8a. Please specify any time(s) of the day or week when you are not available.

8b. Please specify any time(s) of the year that you are not available.

Interviewer application: Champaign-Urbana 4

9. What is the maximum number of hours per week that you could devote to interviewing?

hrs/wk

10a. Do you speak any foreign language(s) fluently?

Yes

No ® (SKIP TO Q.11a)

10b. Which language(s)?

11a. Do you type? Yes

No ® (SKIP TO Q.12a)

11b. How many words per minute?

wpm

12a. Do you currently have a valid driver’s license? Yes

No ® (SKIP TO Q.13)

12b. Do you have unrestricted use of an automobile in good running condition?

Yes

13a. Have you ever been convicted of a crime?

Yes

No ® (SKIP TO Q.14)

13b. If yes, please explain.

Interviewer application: Champaign-Urbana 4

14. List three references, including former employers if possible, who can advise us of your qualifications. (DO NOT LIST RELATIVES OR PERSONAL FRIENDS.)

Interviewer application: Champaign-Urbana 4

[1] Name

Street Address

City, State, ZIP

Phone Number

Interviewer application: Champaign-Urbana 4

[2] Name

Street Address

City, State, ZIP

Phone Number

Interviewer application: Champaign-Urbana 4

[3] Name

Street Address

City, State, ZIP

Phone Number

Interviewer application: Champaign-Urbana 4

15. Where did you hear about this interviewing position? (PLEASE CHECK ALL THAT APPLY.)

Newspaper ad

Posted ad

Another interviewer (PLEASE SPECIFY INTERVIEWER’S NAME)

Some other source (PLEASE SPECIFY)

16. Why are you applying for this particular job?

Signature Date

Please e-mail your completed application to

or fax it to JOBS@SRL at (217) 244-4408

Survey Research Laboratory

505 E. Green St., Suite 3

Champaign, IL 61820

Interviewer application: Champaign-Urbana 4