California State University, San Bernardino - Office of the Dean of Undergraduate Studies
RETURNING GRADUATE ASSISTANT APPLICATION
Please complete all information below and return to Undergraduate Studies (UH 352).
If you are a NEW graduate assistant, please use the Writing Center Tutor Application.
Last First Middle
(Complete if your address or phone number has changed, if no change skip to section B)
No. & Street
City, State & Zip Code
CURRENT TELEPHONE #
I am employed by another CSU campus (where) or CSUSB
department (where) extension .
Please provide current graduate program information below:
Degree Field Institution Year
Master’s / in progress.
Enrolled: Y N # Units: _____
CONTACT IN CASE OF EMERGENCY: (Must be completed)
Optional: Medical Insurance Company & Policy #:
I hereby certify that the information contained in this application is true, complete and correct to the best
of my knowledge.
Signature: SID #: Date: