Application for Spring 2017

SUPPLEMENTAL INSTRUCTION (SI) LEADER EMPLOYMENT APPLICATION, MATHEMATICS DEPARTMENT

A completed application packet must be sent by email to Dr. CadwalladerOlsker ([email protected]) and must include: 1. This application form, filled out electronically. Do not print and scan. 2. A copy of either your TDA or unofficial transcript. See the SI Application website at http://mathfaculty.fullerton.edu/tcadwall/SI.html for full instructions. Applications are due October 28 , 2016 at 5pm. If any of the above materials are not received by this time, your application will be considered incomplete.

Date of Campus Wide ID: Click here to enter text. Application: Click here to enter text. Choose an item. Click here to enter text. (Mr., Ms., Mrs.) Full Name Present Address: Permanent Address: Click here to enter text. Click here to enter text. Street Street Click here to enter text. Click here to enter text. City/State Zip Code City/State Zip Code Click here to enter text. Click here to enter text. Fullerton Email Address Preferred Email Address Click here to enter text. Click here to enter text. Home Phone Cell Phone Are you currently authorized to work in the United States? ☐Yes ☐No If not, please state your current immigration Click here to enter text. status:

Student Status: ☐Graduate ☐Undergraduate Expected Graduation Click here to enter text. Date:

To be an SI leader in the Math department, you must have completed Math 150A, 150B, and 250A with a grade of B or higher. Exceptions will only be made in extraordinary circumstances.

Class Semester Taken and Grade Math 150A Click here to enter text. Math 150B Click here to enter text. Math 250A Click here to enter text. Education – College, University, and other schools in special subjects Name of Location Dates of Attendance Degree, Date received Institution From To Diploma or and Major Number of Subject Units Earned Click here to enter Click here to enter Click here to Click here to Click here to Click here to text. text. enter text. enter text. enter text. enter text. Click here to enter Click here to enter Click here to Click here to Click here to Click here to text. text. enter text. enter text. enter text. enter text. Click here to enter Click here to enter Click here to Click here to Click here to Click here to text. text. enter text. enter text. enter text. enter text. Note: Indicate specialization within the major (i.e. Latin American History, Elementary Education, and Abnormal Psychology). If candidate for a degree, indicate major subject, date degree expected, and awarding institution Please list any of the following: Professional achievements (including publications, memberships in professional and honor organizations), research, and creative activities – indicating sponsoring agencies, if any. Click here to enter text. Why do you want to become an SI leader? How will you motivate students to attend SI? Click here to enter text. Supplemental Instruction, Tutoring, Teaching experience and other Employment (List most recent experience first) Name of Position Title Location Full Time? Date Institution City and State Part time? (if (Month and Year) so, how many From To hours) Click here to enter Click here to enter Click here to enter Click here to Click here to Click here to text. text. text. enter text. enter text. enter text. Click here to enter Click here to enter Click here to enter Click here to Click here to Click here to text. text. text. enter text. enter text. enter text. Click here to enter Click here to enter Click here to enter Click here to Click here to Click here to text. text. text. enter text. enter text. enter text.

Are you now or do you plan to work elsewhere on campus? ☐Yes ☐No

If yes, for how many hours per week? Click here to enter text. Who is or will be your supervisor? Click here to enter text.

Please list 2 references, including the individual who has written a letter of recommendation, that are familiar with your professional and/or academic record that we may contact:

Letter of recommendation from: Additional reference: Click here to enter text. Click here to enter text. Name Name Click here to enter text. Click here to enter text. Position Position Click here to enter text. Click here to enter text. Street Street Click here to enter text. Click here to enter text. City/State Zip Code City/State Zip Code

The above statements are true to the best of my knowledge and belief.

Click here to enter text. Click here to enter text. Signature (Your typed name will serve as your electronic signature) Date