California State University, Fullerton



Application for Fall 2021CALIFORNIA STATE UNIVERSITY, FULLERTONSUPPLEMENTAL INSTRUCTION (SI) LEADEREMPLOYMENT APPLICATION Campus Wide ID:Click here to enter text. Date of Application:Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.First Name legal name Middle NameLast Name Pronouns Present Address:Permanent Address:Click here to enter text.Click here to enter text.StreetStreetClick here to enter text.Click here to enter text.City/State Zip CodeCity/State Zip CodeClick here to enter text.Click here to enter text.Fullerton Email AddressPreferred Email AddressClick here to enter text.Click here to enter text.Home PhoneCell PhoneAre you currently authorized to work in the United States? ?Yes ?NoIf not, please state your current immigration status:Click here to enter text.Student Status: ?Undergraduate ?Graduate Expected Graduation Date:Click here to enter text.I feel qualified to do SI for (check all that apply). To be an SI leader, you must have completed the course with a B or higher. Department Course Accounting ?201B ?301B ?302 Biology ?151 ?152 ?251 Chemistry?120B ?123 ?301A ?301B ?315 Computer Science ?120 ?121 ?131 ?131 ? 240Engineering ?EGCE 201 ?EGEE 203 ?EGME 304 Finance ?320Geology ?101ISDS?361A ?361BKinesiology?348Math ?115 ?125 ?130 ?135 ?150A ?150B ?250A ?250B Physics?211 ?212 ?225 ?226 Political Science?100Psychology ?101 ?300Please list in ranked order the courses you would be interested in being an SI leader for: 1st Choice2nd Choice3rd Choice 4th Choice Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.If offered a position with the SI Program, I understand that I will be required to attend the mandatory pre-semester training the week of Monday, August 16 through Friday, August 20, 2021 from 8:00am-5:00pm. ?Yes, I will attend the training ?No, I am not available If no, please explain Click here to enter text.Please describe your anticipated involvement in campus activities next semester (clubs, organizations, honor societies, etc.). Provide the number of hours per week required for these activities, and if you are a member and/or an officer. Click here to enter text.Why do you want to become an SI leader? Click here to enter text.Supplemental Instruction, Tutoring, Teaching experience and other Employment (List most recent experience first)Name of InstitutionPosition TitleLocationCity and StateFull Time?Part time? (how many hours)Date (Month and Year)FromToClick here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Are you now or do you plan to work elsewhere on campus? ?Yes ?NoIf yes, for how many hours per week?Click here to enter text.Where?Click here to enter text.Please list 2 references that are familiar with your professional and/or academic record that we may contact; your letter of recommendation and/or the SI faculty reference form needs to be provided by one of them. Letter of recommendation from:Additional reference:Click here to enter text.Click here to enter text.NameNameClick here to enter text.Click here to enter text.PositionPositionClick here to enter text.Click here to enter text.StreetStreetClick here to enter text.Click here to enter text.City/State Zip CodeCity/State Zip CodeThe above statements are true to the best of my knowledge and belief.Click here to enter text.Click here to enter text.Signature (Your typed name will serve as your electronic signature)Date ................
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