The Center for Survey Research & Analysis

Telephone Interviewer Application

Work Study Student Labor Non-Student

Name:

LAST

FIRST
M.I. 		 

Local/Dormitory Address:
STREET
CITY
STATE
ZIP 		 
TELEPHONE

Permanent Address:
STREET
CITY
STATE
ZIP 		 
TELEPHONE

Cell Phone: Email: Best number to contact you:

STUDENTS ONLY
Grade Point Average:
Major:
Education:   Freshman   Sophomore
    Junior   Senior
  Masters Ph.D.   Non-Degree
Graduation Date (MM/YY):
HAVE YOU EVER BEEN EMPLOYED BY UCONN OR THE STATE OF CONNECTICUT
  Y   N  
From:
(MM/YY) 		To:

(MM/YY)
Pay Rate
Department:
Duties:
Diploma/Highest Degree:
Additional Skills (i.e., computer, language, typing, other):

Are you 18 or over? Y     N

Do you have a driver's license?
  Y N

Number of hours per week: AVAILABILITY
  Mon AM Mon PM Tue AM Tue PM Wed AM Wed PM Thu AM Thu PM Fri AM Fri PM
    Sat AM Sat PM Sun PM Fall Spring Semester Break Spring Break Summer  

PREVIOUS JOB EXPERIENCE
Place: From:
(MM/YY) 		To:
(MM/YY) 		Title/Duties: Pay Rate:
Place: From:
(MM/YY) 		To:
(MM/YY) 		Title/Duties: Pay Rate:
Place: From:
(MM/YY) 		To:
(MM/YY) 		Title/Duties: Pay Rate: