APPLICATION FOR MATH LEARNING ASSISTANT
Fall 2013

(Please complete ALL questions on this form!)
Date:  05/05/2013
Gender:  Male    Female
Name:
  last First Middle
UT EID:
A SSN must be provided at the time of actual employment.
(A SSN documentation must be provided by the 3rd working day, or your employment will be terminated.)
E-mail:
Phone:
Address:
(If possible, list the address and phone you will have at the start of the next semester)
Departmental use only

Hours/Week:
Hourly rate:
Monthly rate:
Total Stipend:
Base rate:
Grading:

1) Have your worked previously for UT?       Yes    No

2) Will you be holding another position at UT or any other State agency
during the semester for which you are applying? 		 Yes    No
 If yes, please list Agency and/or Department and Title:
 Hours per week: Hourly rate:

3) Are you related to any University employee or Regent?  Yes    No
 If yes, give person's name, relationship, position and department:
 

4) Citizenship:  US Citizen    Non-citizen    Non-citizen permanent resident
Ethnic group:  White    Hispanic    Asian    Black    American Indian    Other

5) a. Number of hours you will be registered for during the next semester:
b. Classification:  Fr    So    Jr    Sr  
School/College:   Major:

6) Number of hours you prefer to work:
(most are appointed at 16 hrs. a week for 2 courses)

7) If you are not a Texas resident, will you be seeking a tuition waiver
(to be eligible for in-state tuition)? 		    Yes    No  


UNDERGRADUATE COURSES:
Course Where Taken Grade
M302
M305G
M408C
M408D
M408K
M408L
M408M
M408N
M408S
M316
M316K
M316L
M325K
M427K
M427L
M328K
M333L
M340L
M341
M343K
M348
M358
M358K
M360M
M361
M361K
M362K
M364K
M365C
M365D
M367K
M367L
 
Course Where Taken Grade
M368K
M372
M373K
M373L
M374
M374K
M378K

ACTUARIAL MATH:
ACF329
M339U
M339W
M439V
M439J
M349P

OTHER COURSES: (not mentioned above)
 
 
 

  I consent to a release of my records for determination of my eligibility for employment.
   
Any student assistant, who, subsequent to this appointment, accepts any other University/State employment without notifying the learning assistant coordinator or who falsfies any information on this application, will be subject to immediate removal from his/her Mathematics appointment.