Reference Sheet Form (You need two references)

Administration Policy on Student Attire Verification Form

Presidential Policy on Use of University Electronic Resources Verification Form

Use of Personal Cell Phones During Business Hours Verification Form

Employee Direct Deposit Authorization Form

Career Services Student Internship Agreement Form

Commonwealth of Virginia Application for Employment

Authorization for Release of Information Form

Criminal History Record Request Form

Payment of Child Support Disclosure Form

Unofficial Transcript

Resume’

Student Intern’s Hiring Forms Checklist

Position Number:

Job Title:

Personal Information First Name:

Middle Name:

Last Name:

Suffix:

Address:

City:

State:

Zip Code:

Country:

Primary Contact Number:

Alternate Contact Number:

Other Contact Number:

Email Address:

Check which shift you will accept: Day Evening Night Rotating Weekends

Specify shift hours:

Check all employment statuses you will accept: Full-time Part-time Hourly/Wage Weekends

If Part-Time, specify:

Are you willing to accept employment which requires you to travel? No Yes, during the day

only Yes, occasionally

overnight Yes, frequently

overnight Weekends

Indicate the geographic locations in which you are willing to work. All Central

Virginia Northern

Virginia Hampton Roads Southwest

Virginia Southside

Virginia

Are you willing to provide your own transportation if necessary for your employment?:

For purposes of compliance with The Immigration Reform and Control Act, are you legally eligible for employment in the United States?:

Section 2.2-2804 of the Code of Virginia prohibits any board, commission, department, agency, institution or instrumentality of the Commonwealth from employing a person who is required to present himself and submit to the federal Selective Service registration requirement and failed to do so. If you are/were required to register for the Selective Service, have you done so?

If no, state reason:

For purposes of compliance with Section 2.2-2903 of the Code of Virginia, are you a veteran who received an honorable discharge and has (i) provided more than 180 consecutive days of full-time active- duty in the armed forces of the United States or reserve components thereof, including the National Guard, or (ii) has a service-connected disability rating fixed by the United States Veterans Affairs?

If yes, did you serve during the Vietnam Conflict 22861-3775?:

Are you a veteran who has been honorably discharged and has a service-connected disability rating fixed by the U.S. Veterans Affairs?:

When will you be available to start work?:

Educational Information Indicate highest grade completed grade school and high school:

If you did not complete high school, do you have a high school equivalency diploma?:

Indicate number of years of post high school education:

Educational Institutions Name of College / University / Vocational School:

Credit/Hours:

Degree if applicable:

Major or Specialty if applicable:

Minor if applicable:

Begin Date:

End Date leave blank if still attending:

Work Experience References May we contact your present supervisor?:

Name of Reference:

Address:

Phone Number:

E-mail Address:

Relationship:

Name of Reference:

Address:

Phone Number:

E-mail Address:

Relationship:

Name of Reference:

Address:

Phone Number:

E-mail Address:

Relationship:

Conviction Question Have you ever been convicted* for any violation(s) of law, including moving traffic violations? *Convictions include Virginia juvenile adjudications for Capital Murder, First and Second Degree Murder, or Aggravated Malicious Wounding, if you were age fourteen (14) to eighteen (18) when charged. A conviction does not automatically disqualify you from all jobs. A conviction will be judged on its own merits with respect to time, circumstances, seriousness, and the extent to which it is related to the job for which you are applying.

Criminal History Description of offense:

Statute or ordinance if known :

Date of Charge:

Date of Conviction:

County, City, State of Conviction:

Additional Information How did you hear about employment opportunities with the Commonwealth of Virginia? Newspaper (name) Radio/TV (name) VEC: State RMS system Agency Bulletin Board Other (please specify)

Use this space for any additional information you think would help us evaluate your application, including training, seminars, workshops, and special achievements or specialized skills:

Automated word processing hardware software:

Licenses Type:

License Number:

Granted by licensing board:

Type:

License Number:

Granted by licensing board:

Agreement I hereby certify that all entries on both sides and attachments are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment in the service of the Commonwealth of Virginia. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent that you may contact references, former employers and educational institutions listed regarding this application. I further authorize the Commonwealth to rely upon and use, as it sees fit, any information received from such contacts. Information contained on this application may be disseminated to other agencies, nongovernmental organizations or systems on a need-to-know basis for good cause shown as determined by the agency head or designee. BY SIGNING BELOW, I certify that I have read and agree with these statements.

Applicant's Name Applicant's Signature Date

Virginia State University Criminal History Record Request

Date: ______________________

Office of Human Resources

__________________ ___________________ _____________________ Last Name First Name Middle Name __________________ ___________________ ______ __________ Street City State Zip Code Sex: ________ Race: ___________________ Date of Birth: __________ ___________________________ __________________________ Place of Birth (County or City) Place of Birth (State or Country) Social Security Number: ____________________________________________ If you have been known previously by a different name(s), include name(s) here: Last Name First Name Middle Name ________________________________________________________________

AFFIDAVIT FOR RELEASE OF INFORMATION

I understand that as a condition of my employment, Virginia State University will conduct a Criminal History Record and Sex Offender & Crimes Against Minors Registry check. Signature of Applicant Position Number and Title: ______________________________________

NOTE: Applicants who decline to complete this form will be denied the interview and will receive no further consideration for the position. Information received regarding the Criminal History Record and Sex Offender & Crimes Against Minors Registry search may void your offer of employment and/or contract. Revised Date: September 12, 2012

Administration and Finance Interns

Sign – In Sheet

Name Date Time In

Time Out

Time In

Time Out

Total Hours Verified By

**Complete the highlighted areas only**

REFERENCE SHEET CONFIDENTIAL INFORMATION

1. Applicant’s Name: ________________________________________________________

2. Employment History:

Name of Organization_____________________________________________________ Dates of Employment: From________________ To_________________ Position Held: ___________________________________________________________ Salary: Starting______________ Final_______________ Attendance Record: ______________________________________________________ Reason for Leaving: ______________________________________________________ Would you rehire this former employee? _____Yes _____No

3. Training Completed:

Identify any training completed by this individual while in you employ

_______________________________________________________________________ 4. Work Habits:

Describe the quality of work performed by this individual: _________________________ _______________________________________________________________________

5. Verification of special requirements: (Identify date issued) Licensed Held ___________________________________ Certificate ___________________________________ Degree ___________________________________ 6. Name of Individual providing reference, title and phone number:

_______________________________________________________________________ 7. Additional reference comments: _____________________________________________ _______________________________________________________________________ _______________________________________________________________________ NOTE: Questions 1-6 are in compliance with DPT Selection Policy 2.62 Verified by: __________________________________ Date: ___________________________

VIRGINIA STATE UNIVERSITY PETERSBURG, VIRGINIA 23806

P.O. Box 9213 (804) 524-5996

(804) 524-5347 FAX Office of Risk Management TDD (804) 524-5487

“VSU: Education, Research and Community Service in Central and Southside Virginia…” An Equal Opportunity Employer/Equal Access Institution

ACTION MEMORANDUM

TO: Administration and Finance Student Interns

FROM: Dale Mason, Director of Risk Management

DATE: May 13, 2008

RE: Use of Personal Cell Phones during Business Hours

The purpose of the memo is to define how Administration and Finance Student Interns employees use their personal cellular phones for personal use during University work hours. Personal Calls and or text messages should not interfere with your work performance. While we are not restricting total use of your personal cell phone during work hours, we are restricting use of your personal cell phone to your break times and a maximum of two minute per hour for calls and/or sending/receiving text messages. Cell phones used during work hours beyond the two minute period should be a genuine emergency.

PERSONAL CELLULAR PHONE GUIDELINE

My signature verifies that I have received and read Administration and Finance Student Interns guidelines on use of Personal Cellular Phones.

_______________________________________________________________________ SIGNATURE DATE

Career Services Virginia State University

P.O. Box 9410 Petersburg, Virginia 23806 Telephone: 804-524-5211

Fax: 804-524-5212 www.vsu.edu/pages/301.asp

THE INTERNSHIP PROGRAM Field Experience -- Learning Opportunity

STUDENT INTERNSHIP AGREEMENT

Please Read Carefully

I, _____________________________________ ID #V ____________________ am a student at Virginia State ( Student Name - Please Print) University and plan to undertake an internship during the Spring 20___; Summer 20___; Fall 20___; semester(s) at the following location: _______________________________________ _____________________________________________ (Internship Site) (City/State/Country) Virginia State University itself does not control the way in which this educational opportunity is structured or operates. In granting credit for this internship, the University affirms that, to the best of its judgment, the experience is an appropriate curricular option for students in an Agriculture; Business; Engineering, Science, and Technology; Liberal Arts and Education, or Graduate Studies, Research and Outreach program of study and worthy of Virginia State University credit but makes no other assurances, expressed or implied, about any travel and living arrangements the student has made. Virginia State University does not knowingly approve internship opportunities, which pose undue risks to their participants. However, any internship or travel carries with it potential hazards which are beyond the control of the University and its agents or employees. PERSONAL CONDUCT

I understand that the responsibilities and circumstances of an on-campus or off-campus internship may require a standard of decorum, which may differ from that of Virginia State University, and I indicate my willingness to understand and conform to the standards of the internship site. I further understand that it is important to the success of the present internship and continuance of future internships that interns observe standards of conduct that would not compromise Virginia State University in the eyes of individuals and organizations with which it has dealings.

I agree that should the Academic Advisor, along with the Internship Program Coordinator, decide that I must be terminated from my internship because of conduct that might bring the program into disrepute or the internship site into jeopardy, that decision will be final and may result in the loss of academic credit.

EVALUATING AND MONITORING THE INTERNSHIP

Upon accepting an internship assignment, it is my responsibility to perform all tasks assigned to me to the best of my ability, to meet all the standards and conditions of my employment, and to abide by the work schedule established by my employer.

To earn a grade(s) and/or credit(s) for my internship assignment, it is my responsibility to gain approval from my Academic Advisor, seek and follow the procedures for registering for the internship.

The academic department/Academic Advisor is responsible for evaluating my work performance for the purpose of assigning a grade(s) and/or credit(s). In deciding on a grade, most Academic Advisors make extensive use of the information that has accumulated during the monitoring of the internship, and they supplement this information with evaluative information from the intern and the site supervisor. Most departments require some kind of captstone project, often a term paper or final report written by the intern, summarizing, synthesizing, and evaluating the learning experiences of the internship.

EMPLOYER INFORMATION

Name of Employer Sponsor ______________________________________________ Name of Site Supervisor ______________________________________________ Site Supervisor's Position Title ______________________________________________ Mailing Address ______________________________________________ ______________________________________________ ______________________________________________ City ________________ State _____________________

Zip Code _____________ Telephone ( ) ___________________ Facsimile ( ) ___________________ E-mail ____________________________

Once having accepted an internship assignment, I will not seek out or accept an internship assignment with any other host organization (employer) for the same semester(s). STUDENT SIGNATURE: ________________________________________ DATE: ______________________ DATE OF BIRTH: ________________ AGE: _____ PARENT/GUARDIAN SIGNATURE: ______________________________________________________________ (If student is under the age of 18 at time of internship) DATE: __________________

ACADEMIC INFORMATION

STUDENT’S MAJOR: ___________________________________ CONCENTRATION: _________________________ ARE YOU PLANNING TO EARN ACADEMIC CREDIT? □ Yes □ No

• If yes, please contact your Academic Advisor in reference to the procedures and guidelines regarding the registration process to earn academic credit.

ACADEMIC ADVISOR: ________________________________ GRADUATION DATE: _____________________ TELEPHONE: ______________________ E-MAIL: _______________________________________________

SCHOOL ADDRESS HOME ADDRESS ___________________________________________ _________________________________________ ___________________________________________ _________________________________________ City State Zip Code City State Zip Code Telephone: ______________________________ Telephone: ________________________________ E-mail: ______________________________ E-mail: ___________________________________

Cellular Phone: _________________________________ ************************************************************************************************************

THE INTERNSHIP PROGRAM

“Learning In Action”

Mrs. Darrell Mallory Easter Career Counselor/Internship Program Coordinator

Telephone: 804-524-5407 E-mail: deaster@vsu.edu

VIRGINIA STATE UNIVERSITY

P.O. Box 9208, Room 45 Petersburg, Virginia 23806

"VSU: Education Research and Community Service in Central and Southside Virginia..." An Equal Opportunity Employer/Equal Access Institution

ACTION MEMORANDUM

TO: Administration and Finance Student Interns FROM: Dale Mason

Director of Administrative Reporting and Cost Analysis

DATE: August 25, 2009 RE: Administration Policy on Student Interns Attire Attached is a copy of the Administration and Finance Policy 5000. The policy name is “Student Interns Attire Policy.” The Policy addresses the proper dress code for student interns. Take time to review the important topics addressed in this policy.

• Purpose • Authority, Responsibility and Duties • Definitions • Policy Statement • Procedure

You will be given a Policy Review sigh sheet to verify that you have received and reviewed the policy. Violation of this policy will result in disciplinary actions.

Page 2 of 2

Administration and Finance Policy 5000 “Student Interns Attire Policy”

My signature verifies that I have received and read Administration and Finance Policy 5000.

_________________________________________________________________________________ SIGNATURE DATE

VIRGINIA STATE UNIVERSITY

P.O. Box 9208, Room 45 Petersburg, Virginia 23806

"VSU: Education Research and Community Service in Central and Southside Virginia..." An Equal Opportunity Employer/Equal Access Institution

ACTION MEMORANDUM

TO: Administration and Finance Student Interns FROM: Dale Mason, Director of Risk Management

DATE: June 3, 2008 RE: Presidential Policy on Use of University Electronic Resources (Computers) Attached is a copy of the Virginia State University Presidential Policy 212 named “Acceptable Use Policy for Electronic Resources and Systems”. The Policy address the property use of the computers assigned to you for job-related purposes. Take time to review the important topics addressed in this policy.

• Purpose • Scope • Definitions • Policy • Violation of Policy • Restrictions on Access to Materials with Sexually Explicit content. • Procedures for Obtaining Approval to Access Material with Sexually Explicit content

You will be given a Policy Review sigh sheet to verify that you have received and reviewed the policy. Violation of this policy will result in disciplinary actions.

Presidential Policy 212 “Acceptable Use Policy for Electronic resources and System”

My signature verifies that I have received and read Virginia State University Presidential Policy 212.

_________________________________________________________________________________ SIGNATURE DATE

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize Virginia State University, Commonwealth of Virginia, to investigate my background in connection with my application for employment. This may include information from any schools attended, personal and/or professional references, previous/present employers, or other sources deemed necessary for my employment. Applicant (Signature) Date Position Title Position Number