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E-MAIL: 

SCHOOL ADDRESS:

SCHOOL PHONE NUMBER: 

HOME ADDRESS:

HOME PHONE NUMBER: 

MAJOR: 

MAJOR GPA:  OVERALL GPA:  

LIST UNIVERSITY ACTIVITIES:

ARE YOU PRESENTLY EMPLOYED ANYWHERE? Yes No

IF YES, WHERE? 

NAME AND PHONE NUMBER OF YOUR SUPERVISOR

HOW MAY HOURS PER WEEK? 

LIST THE NAMES, TITLES, ADDRESS AND CURRENT PHONE NUMBERS OF THREE REFERENCES:

REFERENCE #1:


REFERENCE #2:


REFERENCE #3:

HAVE YOU EVER BEEN CHARGED WITH A CRIMINAL OFFENSE?

Yes

No

IF YES, WHAT WERE YOU CHARGED WITH?

WHEN WERE YOU CHARGED/ARRESTED?

WHERE WERE YOU CHARGED/ARRESTED?

HAS YOUR NAME EVER APPEARED IN A STUDENT AFFAIRS AND/OR PUBLIC SAFETY INCIDENT REPORT IN A NEGATIVE FASHION?

Yes

No

IF YES, STATE WHY:

LIST THE NUMBER OF TIMES YOU HAVE RECEIVED A DISCIPLINARY LETTER FROM THE STUDENT AFFAIRS DEPARTMENT: 

FOR EACH LETTER YOU HAVE RECEIVED, STATE WHY YOU RECEIVED THE LETTER:

ARE YOU WILLING TO SIGN A CONSENT FORM SO WE CAN CONDUCT A THOROUGH BACKGROUND CHECK ON YOU AND THE INFORMATION YOU HAVE GIVEN US?	Yes	No
ARE YOU WILLING TO WORK ODD HOURS (INCLUDING, BUT NOT LIMITED TO EVENING, LATE EVENING AND WEEKEND HOURS)?	Yes	No
ARE YOU WILLING TO WORK FROM 1800 HOURS THROUGH 0200 HOURS (6 PM - 2 AM)?	Yes	No
ARE YOU WILLING TO WEAR A UNIFORM?	Yes	No

WHY DO YOU WANT TO BECOME A UNIVERSITY OF SCRANTON STUDENT PUBLIC SAFETY OFFICER?

DEFINE "ROLE MODEL" AS YOU BELIEVE IT APPLIES TO BEING A UNIVERSITY OF SCRANTON STUDENT PUBLIC SAFETY OFFICER.