General Application for

On-Campus Student employment

Student Instructions: Office of Student Employment
1. Please make sure all sections are filled out completely.
2. Please return a copy of this application with the hire paperwork.

Position Request Section:

Title of requested position Department Name
Employment Period (check all that apply): ✔ Fall ✔ Spring ✔ Summer

Student Section:
Student Applicant’s Name Chynna Joy Canizares APU ID# 002238156
Class: ✔ Freshman Sophomore Junior Senior Graduate Social Security No. 602624332
How many units will you have during the requested employment period? 17 Major Psychology
List the amount of hours you are available to work during the week: List them by day as follows:
Mon. 8 AM to 2 PM Tues. 4:30 to 9 PM Wed. 8 AM to 12 PM Thurs. 4:30 to 10 PM Fri. 8 AM to 2 PM
3:30 to 10 PM to to to 3:30 to 10 PM

APU Address Home Address

APU living area/room# Adams Hall, Room 315 Home Address 16443 Los Coyotes
APU Box# City Fontana State CA ZIP 92336
APU Phone ( 909 ) 569 - 7720 Home Phone ( 909 ) 452 - 7464

In case of an emergency:
Emergency Contact Name Christina Canizares Phone ( 909 ) 560 - 1167 Relationship Mother
Address 6536 Palomar Court City Rancho Cucamonga State CA ZIP 91701

Student Education or Training: (vocational, technical or other)

Name and Location of School Subject Emphasis Certificate/Degree Received

Skills: (such as accounting, clerical, computers, software programs, purchasing, mechanic, interpreter, etc.)
Please list those relevant skills for which you have experience or proficiency:

(Continued on back)
Office Use Only:

Date Received ______/______/______ Date of Interview ______/______/______ Follow up Date ______/______/______

SE Revision 06/28/07
 General Application for
On-Campus Student employment
Student Work History: Office of Student Employment

Employer Name Tokyo Wako Job Title Hostess

Employment Period From / / to / / End Wage $ 8.00
Supervisor Name Eddie Lopez Phone ( 909 ) 484 - 7200
Employer Address 4480 Ontario Mills Pkwy. City Ontario State CA ZIP 91764
Reason for Leaving School; not enough hours.

Employer Name Abercrombie & Fitch Co. Job Title Model

Employment Period From / / to / / End Wage $ 8.00
Supervisor Name Jason Phone ( 909 ) 484 - 8223
Employer Address Suite 1, 1 Mills Circle City Ontario State CA ZIP 91764
Reason for Leaving School

Have you ever worked at Azusa Pacific University? ................................................................................................. Yes ✔ No

Do you have a legal right to accept employment in the United States?...................................................................... ✔ Yes No
Are you a veteran of the United States? ..................................................................................................................... Yes ✔ No
Do you have any physical or mental condition that prevents you from performing any of the essential functions
of the position for which you are applying? ............................................................................................................... Yes ✔ No
Have you been convicted of a felony within the past 7 years? (If Yes, please explain below.)................................ Yes ✔ No

(Conviction will not necessarily disqualify you from employment.)

Student Certification:
I hereby certify the information contained in this application is true and correct to the best of my knowledge and Azusa Pacific University is hereby
authorized to verify the information unless indicated to the contrary. I authorize the references listed herein, as well as all other individuals whom the
university contacts, to provide the university any and all information concerning my previous employment and any other pertinent information. Further,
I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the university, as well as
from the use or disclosure of such information by the university or any of its agents, employees, or representatives. I understand that any
misrepresentation, falsification, or material omission of information on this application may result in disqualification from employment, or if I am hired,
my dismissal from employment.

In consideration of my employment, I agree to conform to the rules and standards of the university, as amended by the university from time to time at its
discretion. I further agree that my employment and compensation can be terminated at will, in accordance with the policies outlined in the student
handbook.

I also understand that all offers of employment are conditional on the provision of satisfactory proof of my identity and legal authority to work in the
United States.

I understand that no offer of salary or benefits is final until approved by the university’s Office of Student Employment.

Student Signature Date

Azusa Pacific University does not discriminate on the basis of race, color, national origin, gender, age, disability, status as a veteran, or
other characteristics protected by law in its programs, policies or procedures. Minorities and women are urged to apply.

Office of Student Employment • Azusa Pacific University

PO Box 7000 • Azusa, CA 91702-7000 • Phone (626) 815-6000, Extension 3558
www.apu.edu
SE Revision 06/28/07