Your Email: ______________________

Referred By: _____________________

APPLICATION FOR STUDENT EMPLOYMENT

Today’s date: ____________________

NAME: _______________________________________________________________________________
Last First Middle Mobile Phone

ADDRESS: ____________________________________________________________________________
# and Street City State Zip Code Home phone

POSITION APPLYING FOR: ________________________________________________________________________________________

EDUCATION: List Education THAT YOU HAVE COMPLETED beginning with most recent
Name and Location of School Major Diploma/Degree

____________________________________________________________ ___________________________ ___________________

____________________________________________________________ ___________________________ ___________________

____________________________________________________________ ___________________________ ___________________

WORK EXPERIENCE: List Employment beginning with most recent. Attach addition sheets if necessary.

1. Name of employer: __________________________________________________________ Employed from ________ to ________

Address of Employer: __________________________________________________________________________________________

Your Title: __________________________________ Your Duties: ______________________________________________________

Supervisor’s Name and Title: ______________________________________________________ May we contact: _____Yes _____No

Supervisor’s Phone: ___________________________________________ Reason for Leaving: _______________________________

WORK EXPERIENCE:
2. Name of employer: __________________________________________________________ Employed from ________ to ________

Address of Employer: __________________________________________________________________________________________

Your Title: __________________________________ Your Duties: ______________________________________________________

Supervisor’s Name and Title: ______________________________________________________ May we contact: _____Yes _____No

Supervisor’s Phone: ___________________________________________ Reason for Leaving: _______________________________

In accordance with federal and state laws, no person in whatever relationship with University at Buffalo, The State University of New York shall
be subject to discrimination on the basis of age, religion or creed, color, disability, national origin, race, ethnicity, sex, marital or veteran status.
Additionally Governor Cuomo’s Executive Order 28 and the University Board of Trustees Police prohibit discrimination on the basis of sexual
orientation.

You must complete both sides

 UNIVERSITY AT BUFFALO POLICE IS AN EQUAL OPPORTUNITY/AFFIRMATIVE EMPLOYER

1. Are you 18 years of age or older? _______ Yes _______ No

2. Are you a citizen of the United States? _______ Yes _______ No

3. Do you have the legal right to accept employment

in the United States? _______ Yes _______ No

4. You must have a social security number to apply,

do you have a social security number? _______ Yes _______ No

5. Have you ever been convicted of a criminal offense? _______ Yes _______ No
If “YES”, please explain: ____________________________________________________________________________________________
NOTE: Conviction does not represent an automatic bar to employment. Each case is evaluated in relation to the duties and responsibilities of the position for which
you are applying for.

6. Have you worked for SUNY or New York State before? _______ Yes _______ No
If “YES”, please indicate:

Name of employer: __________________________________________________________ Employed from ________ to ________

Address of Employer: __________________________________________________________________________________________

Your Title: __________________________________ Your Duties: ______________________________________________________

Supervisor’s Phone: _________________________________ Reason for Leaving: _______________________________
7. List clerical, laboratory, or technical skills you have, licenses, and any office or heavy
machinery you can operate, which relate to the position you are applying:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Persons offered employment in various student positions are required to pass a medical examination to determine the ability of an employee to
perform job related functions. An application may request needed reasonable accommodation to perform job related functions. All information
will be treated as a confidential medical record.

I understand that acceptance of my application for employment in no way obligates the University Police, and that any misrepresentation by
me in this application will be sufficient cause for cancellation of the application and/or for separation from the University Police service if I have
been employed. Except for any contact restriction noted in Work Experience No. 1, I authorize investigation of all statements contained in this
application. I also certify that all answers are correct to the best of my knowledge.

IF WE CANNOT READ YOUR APPLICATION INCLUDING YOUR EMAIL ADDRESS, THIS

APPLICATION WILL BE DISCARDED. YOU MUST ATTATCH A COPY OF YOUR UBID CARD.

________________________________________________________________
Signature

Return to: University Police, University at Buffalo, State University of New York, Bissell Hall, Buffalo, NY 14226

NOTE: Completed applications are considered active for three months from the date they are
received. You will have to submit a new application if you wish to be considered for vacancies
which are posted after that date.