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Summer Academy 2013

Resident Assistant
Application
Debi Martinez-Brun - Upward Bound Program Director
Colorado Mountain College
dbrun@coloradomtn.edu
Return Application with rsum
150 Miller Ranch Road
fax: 970.569.2963
and cover letter to:
Edwards, CO 81632
We do not discriminate on the basis of race, color, religion, national origin, sex, age, or disability. It is our intention that all
qualified applicants be given equal opportunity and that selection decisions be based on job related factors.

General Information (Please Print):


Name: ____________________________________________________________________________
Mailing Address: ______________________________________________________________________
__________________________________________________________________
City

State

Primary Phone: ____________________________


Do you have a valid driver's license?

Yes

Zip

Other Phone: _____________________________

No

Are you a US Citizen?

Issuing State:______________________________

Yes

No

_________________________________________
If not a citizen, your permanent resident number

License #:_______________________________

Education (Please Print):


Are you currently enrolled in college?

Yes

No

Please indicate the highest college year completed by May of 2012: _______________
What is your current GPA: _______________
What is your major: _______________
List the classes that you would be comfortable tutoring and/or assisting with teaching:

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Current Employment (Please Print):
Current Position:______________________________________________
Company Name: _______________________________________________________
Supervisor's Name:______________________________________________
Supervisor's Phone:______________________________________________
Do we have your permission to contact your supervisor?
3/6/2013; 2:25 PM

Yes

No
Created: 03/24/2008

Professional References
Name

Phone

Address

Title

1. ____________________________________________________________________________
2. ____________________________________________________________________________
Do you have a current American Red Cross First Aid/CPR card? Yes
Have you ever been convicted of a felony?

Yes

No

No

Optional: If your rsum or cover letter does not include the information below,
please limit your response to the space provided:
Why are you interested in working with the CMC-Upward Bound Summer Program?

List your experiences working with disadvantaged or ethnically diverse high school students:

List your personal abilities, interests, or hobbies that you would like to share with high school students.
(Please include academic, athletic, artistic, musical, multicultural, international interests, etc.)

I understand that by my signature below I am testifying that what is stated above is factual and accurate.
If
any of this information is determined to be inaccurate or false I will be subject to disciplinary action up to and including
loss of employment. I also understand that any offer of employment is contingent upon a professional background check
with the pertinent state and federal agencies.

_________________________________________

_________________________________________

Signature

Date of Signature

3/6/2013; 2:25 PM

Created: 03/24/2008

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