Page 1
Bemidji State University
Department of Public Safety
Click on the box below
to clear this form.
Application for Student Employment
Please Complete Each Item
Classification
____________________________
_____________________
____________________
Last Name
First Name
Full Middle Name
__________________________
Permanent—Street
_____________________
City
_______
State
__________________________
Local/Campus – Street
_____________________
City
________
State
_________
Zip Code
_________
Zip Code
________________
Telephone
_______________
Telephone
FR ______
SO ______
JR ______
SR ______
G ______
Cumulative GPA: ______ Study Major: _____________ Financial Aid: Federal Work Study: Yes ____ No ____ Amount $_____
Date Available: _________ Hours Per Week:____
Able To Work Over Summer: Yes____ No_____
Able To Work Weekends: Yes____ No____
Able To Work Overnight Hours: Yes____ No_____
Social Security Number: ______ ____ _______ Driver’s License #: __________________________ State of Issue: ________
Driving Violation(s): Date: ______________ Charge: ___________________ Disposition: _____________________________
Date: ______________ Charge: ___________________ Disposition: _____________________________
Date: ______________ Charge: ___________________ Disposition: _____________________________
Criminal History:
Date: ______________ Charge: ___________________ Disposition: ______________________________
Date: ______________ Charge: ___________________ Disposition: ______________________________
Date: ______________ Charge: ___________________ Disposition: ______________________________
University Conduct Date: ______________ Charge: ___________________ Disposition: _______________________________
Violation(s):
Date: ______________ Charge: ___________________ Disposition: _______________________________
Date: ______________ Charge: ___________________ Disposition: _______________________________
Skills: First Aid -- Yes ____ No ____ Cert. __________ Self Defense -- Yes ____ No ____ Report Writing -- Yes ____ No ____
_________________________________________Confidential Information__________________________________________
Informed Consent:
The Department Public Safety at Bemidji State University is required by law to do a criminal history background investigation
on all security employees. The following information is required in order to complete the inquiry.
Place of Birth: Country ________________________ State ________________________ City _____________________________
Date of Birth: ____________________ Height _____ Weight _____ Hair Color _____ Eye Color _____ Gender _____ Race _____
I understand that the information provided in this section will be used to conduct a criminal history background investigation.
________________________________________
Signature of Applicant
________________________________
Date
This is the end of page 1 of 2 pages.
A completed hard copy of this application must be submitted to:
Bemidji State University, Department of Public Safety, 1500 Birchmont Dr.
NE, Bemidji, MN, 56601.
Bemidji State University is a affirmative action/equal oppurtunity educator and employer.
Public Safety Application Page 1
Revised, Febuary 14 2008
Page 2
Bemidji State University
Department of Public Safety
Click on the box below
to clear this form.
Application for Student Employment
References
Past Employers: _________________________
Acquaintances
_________________________
____________
____
______________
Company/Business/Organization
Street Address
City
State
Telephone
_________________________
_________________________
____________
____
______________
Company/Business/Organization
Street Address
City
State
Telephone
_________________________
_________________________
____________
____
Name
Street Address
City
State
Telephone
_____________
_________________________
_________________________
____________
____
______________
Name
Street Address
City
State
Telephone
Essay
Please write a short essay indicating why you would like to work as a Student Public Safety Officer for the Department of Public
Safety at Bemidji State University.
_______________________________Office Use Only Below This Line_______________________________
Date Interviewed: _______________________ Date Hired: _______________________ Interviewer: _________________________
Date Terminated: _______________________ Reason for Termination: _________________________________________________
Uniform Articles Issued:
Polo Shirt: Qty __ Size ______ Winter Jacket: Size__________
____________________________________________________________________________________________________________
This is the end of page 2 of 2 pages.
If you are accessing this application on the Internet, print this page and submit hard copies of both page 1 and page 2 to:
Bemidji State University, Department of Public Safety,
1500 Birchmont Dr. NE, Bemidji, MN, 56601.
Bemidji State University is a affirmative action/equal oppurtunity educator and employer.
Public Safety Application Page 2
Revised, Febuary 14 2008