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NEAL-MARSHALL BLACK CULTURE CENTER

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					                NEAL-MARSHALL BLACK CULTURE CENTER
                          INDIANA UNIVERSITY
                     275 North Jordan Avenue, Suite A226
                           Bloomington, IN 47405
                                (812) 855-9271
                             nmbcc@indiana.edu

         WORK STUDY and HOURLY EMPLOYMENT APPLICATION

NAME:_______________________________________________
           Last              First           Middle

LOCAL ADDRESS:____________________________________

             _____________________________________
               City        State       Zip Code
PHONE NUMBER: ___________________________

E-MAIL ADDRESS:____________________________

PERMANENT ADDRESS:
_________________________________________________
_________________________________________________
City              State             Zip Code

PHONE NUMBER: __________________________________
E-MAIL ADDRESS: _________________________________

STUDENT ID NUMBER: _____________________________

INDICATE TERMS YOU WILL BE/ARE PLANNING TO ENROLL AT IUB:

FALL 20______     SPRING 20______     SUMMER 20______

INDICATE WHETHER YOU HAVE WORK STUDY THIS SEMESTER:

FALL 20_____      SPRING 20______     SUMMER 20______

INDICATE YOUR CURRENT CUMULATIVE GRADE POINT AVERAGE: _______

PLEASE MARK YOUR FOLLOWING CLASSIFICATION:

FIRST YEAR___SOPHOMORE___ JUNIOR___SENIOR____GRADUATE___

MAJOR:________________________      MINOR:______________________________
HAVE YOU TAKEN ANY AFRICAN AND/OR AFRICAN AMERICAN COURSES?
YES_____                            NO_____
WHAT COURSES HAVE YOU TAKEN? ___________________________________
______________________________________________________________________


PREVIOUS EMPLOYEE AT THE NMBCC:
YES_____                      NO______
HOW MANY SEMESTERS HAVE YOU WORKED AT THE NMBCC? ___________

WHEN? _________________________

IF EMPLOYED, WHAT HOURS AND TIMES COULD YOU WORK? (GIVE YOUR
CLASS SCHEDULE TO the N-MBCC ADMINISTRATIVE ASSISTANT)

HOW MANY HOURS ARE YOU ABLE TO WORK PER WEEK? ________________

PLEASE PROVIDE A SUMMARY OF YOUR SKILLS AND HOW THESE SKILLS
WOULD APPLY TO THE SUCCESS OF THE NMBCC:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________________________________
PLEASE PROVIDE A SUMMARY OF YOUR PERSONAL QUALITIES AND HOW
THESE QUALITIES WOULD APPLY TO THE SUCCESS OF THE NMBCC:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

WHAT BENEFITS DO YOU HOPE TO ACHIEVE FROM THIS EXPERIENCE?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________________________________
______________________________________________________
REFERENCES:

PLEASE LIST THREE REFERENCES INCLUDING JOB SUPERVISOR(S),
ACADEMIC COUNSELORS , STAFF OR FACULTY REFERENCES WHO COULD
PROVIDE INFORMATION CONCERNING YOUR POTENTIAL AS A ROLE
MODEL FOR AFRICANA STUDENTS. (PLEASE NO PERSONAL REFEREES –
FAMILY OR FRIENDS)

NAME: ________________________
POSITION: _______________________________
PHONE #: ______________________
E-MAIL: ______________________________
RELATIONSHIP TO YOU:____________________________

NAME: ________________________
POSITION: ________________________________
PHONE #: ______________________
E-MAIL: ______________________________
RELATIONSHIP TO YOU: _____________________________

NAME: ________________________
POSITION: ________________________________
PHONE #: ______________________
E-MAIL: ______________________________
RELATIONSHIP TO YOU: _____________________________

				
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