Student Academic Center

Associate Instructor Application

   * represents required information.

 Contact Information  Name*: Student ID # (Not your SSN): E-mail Address*:

Current Address:

Street*: City/State/Zip*: Phone (e.g., 812-855-7313)*:

Permanent Address: (Location from April through August)

Street: City/State/Zip: Phone (e.g., 812-855-7313):
 Educational Background 

Undergraduate:

Address: Major/Minor: Graduation Date (mm/dd/yyyy):

Graduate:

Degree (If applicable): Address: Major/Minor: Graduation Date (mm/dd/yyyy):

Current Enrollment:

Current Program: Degree Sought: Major/Minor: Date Admitted (e.g., mm/dd/yyyy): Hours Completed: Expected Graduation Date (mm/dd/yyyy):
 Interest/Honors/Professional Activities 

List your interests, honors, and professional activities:

 Work Experience 

Prior Experience 1: (Please include only those positions relevant to your application for the assistantship)

Employer: Address: Supervisor: Phone (e.g., 812-855-7313): Position: Date of employment (mm/dd/yyyy): Position Responsibilities:

Prior Experience 2: (Please include only those positions relevant to your application for the assistantship)

Employer: Address: Supervisor: Phone (e.g., 812-855-7313): Position: Date of employment (mm/dd/yyyy): Position Responsibilities:

Prior Experience 3: (Please include only those positions relevant to your application for the assistantship)

Employer: Address: Supervisor: Phone (e.g., 812-855-7313): Position: Date of employment (mm/dd/yyyy): Position Responsibilities:
 Candidate Statement 

One Page Candidate Statement*
- Let us know how you view the learning need and issues encountered by college students, how you would help students address these issues, and the resources you would bring to an appointment at the Student Academic Center.