Survey Research Center - Interviewer Application

Today's Date ______

Personal Information

Name(Last, First M.I.) __________________________________

Address _________________________________________ Telephone (_____)________________

City __________________________________ State ______ Zip ___________________________

PSU ID (if applicable) ________________________ Email address ________________________

Work History (Please list in reverse chronological order, starting with your most recent)

Employer _________________________________________ Telephone _____________________

City, State ______________________________ Supervisor's Name ________________________

Job Title/Description ______________________________________________________________

When did you work there? _____________________________ May we call? Y N

Employer _________________________________________ Telephone _____________________

City, State ______________________________ Supervisor's Name ________________________

Job Title/Description ______________________________________________________________

When did you work there? _____________________________ May we call? Y N

References (Please list two. If you did not list an employer as available to contact above, including a telephone number, then please list an employment reference below.)

Name ________________________________________ Company _________________________

Telephone Number _____________________________ Relationship to you _________________

Name ________________________________________ Company _________________________

Telephone Number _____________________________ Relationship to you _________________

Hours of Availability: (Please indicate the hours you will typically be available. Include afternoon and/or evening hours.)

Monday ____________________________________ Friday _____________________________

Tuesday ____________________________________ Saturday ___________________________

Wednesday _________________________________ Sunday ____________________________

Thursday ___________________________________

Will you be available to work when PSU is closed? Y N

Will you be available to work during the summer? Y N

Relevant Skills and Experience (Please indicate any relevant skills or experience such as telephone communication, computer skills, interviewing, etc.)

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
________________________

Please indicate any languages you speak fluently. _________________________________________

How did you learn about this job? ____________________________________________________

Please return completed application to The 330 Building, Suite 105, or email to telsup@ssri.psu.edu