* Is this for the summer or the academic year?
Please fill in the year that you are requesting for.
* Academic Year (i.e. 2013-2014) or Summer (i.e. Summer 2013):
* Student Name:
Student Mailing Address:
* Student ID #:
DO NOT USE STUDENT SOCIAL SECURITY # FOR ID
Student HRMS Employee ID:
* Student Phone #:
* Student CU E-mail:
* Employer Name (Dept/Agency):
* Employer Address/Campus box:
* Employer Phone #:
Employer Fax #:
* Supervisor Name:
* Supervisor E-mail:
Please provide the following information so that we can process your request:
* Average # of hours that you would like to work during the week. Limit 25 hours per week during the AY **:
Student payrate: $
*Enter the combined total # of weeks for BOTH terms that you would like to work (38 total weeks if you plan on working all year, otherwise there are 18 weeks in Fall and 20 weeks in Spring):
*When figuring # of weeks the student will work, please use the schedule of pay periods. Each pay period is two weeks.
**If you are requesting a work-study increase to fund more than 25 hours per week, we ask that the student fax (x2-4544) or email (firstname.lastname@example.org) a letter of explanation addressing how he/she will successfully manage these work hours while maintaining satisfactory academic performance.
* Are you using your work-study with more than one employer? Yes No
If yes, please provide the following information:
Other Supervisor Name:
Other Supervisor E-mail:
Average # of hours that you would like to work during the week:
Student payrate: $
Total # of weeks during both terms* (maximum of 18 weeks in the fall and 20 weeks in the spring) that you would like to work:
* If my only financial aid eligibility consists of accepted loans, I am willing to decline loans in the following amount: $
Other comments/special circumstances:
(Note: Loan funds that have already disbursed must be repaid to the Bursar's Office)