Service Request Worksheet

Please complete and return by June 1, 2011, to MTSU Financial Aid MTSU Scholarship Office, 206 James Union Building, 1301 East Main Service Request Worksheet Street, Murfreesboro, TN 37132, Fax (615)898-5167 If you have been awarded a renewable academic scholarship at MTSU, use this worksheet to request departments in which you wish to complete your service hours. Forms will be processed in the order received. We therefore recommend that you submit this form as soon as you accept the scholarship!

Name: (Please print clearly!)______Student ID: M______Email Address: [email protected] Phone: (______)______Please indicate the type of scholarship you have been awarded: Nat’l Merit/Achievement Chancellor Presidential Academic Service Phi Theta Kappa Transfer Academic Service Valedictorian-Salutatorian Academic Service

Department Requests: You may request up to 4 specific departments, after visiting the webpage at http://www.mtsu.edu/financialaid/forms/SSPDepartments.doc for a list of possible choices. What are your top 4 choices? (We recommend that you fill in all 4 blanks with department choices, for best results!) ______Have you spoken with a supervisor in any of the above departments and made arrangements with them? Yes No If yes, please provide the following information: Department: ______Contact Person: ______If one of the above departments is listed on the website as requiring a separate application, have you submitted the required application? Yes No If yes, please provide the following information: Department: ______Date Submitted: ______We will make every effort to place you in one of your top four choices, but we cannot guarantee such a placement. If we are unable to place you in one of these departments, are there any specific departments in which you definitely do not want to be placed? Yes No If yes, which department(s) and why? ______Your Expected Major (if known):______Minor:______In which academic college is your major (if known)? Basic & Applied Sciences Mass Communications Liberal Arts Education Behavioral & Health Sciences Special Skills: Please list any special skills, knowledge, or abilities you have, which you believe may be helpful in placing you in a department. (Examples: Software you are proficient on, such as Microsoft Word; Talents such as ability to play piano or draw well; etc.) ______Off-Campus Placement: Are you willing to work at an off-campus location? Yes No Some departments are located off-campus (such as Academic Outreach), or have some positions located off- campus (such as Aerospace), as noted on the department website listed above. If you are assigned to an off- campus location, you will be responsible for your transportation to and from the location. You will only be assigned to an off-campus location or position if you agree to the placement and sign a special agreement form. Physical Placement: Do you wish to complete tasks that are physical in nature? Yes No By default, students will complete tasks that are primarily academic or administrative in nature. However, some departments (such as the Campus Cleanup Crew) offer more physical tasks such as picking up trash or moving heavy objects for students who prefer such tasks. You will only be assigned to a position which requires physical tasks if you agree to the placement and sign a special agreement form. For more information, please visit www.mtsu.edu/scholarships/ssp_scholarships.shtml.