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UGA Application Form

If you need to change any information in your application, please e-mail the UGA Recruitment and Selection Committee.

Section A: General Information

First Name: Middle: Last Name:

What is Your Preferred Name?

Date of Birth (mm/dd/yy): Gender:

Languages in which you are proficient:

Are you a U.S. Citizen? Yes No

Dartmouth ID#: Class Year:

Hinman Box: E-Mail:


Off-Campus Contact (or cell) Phone Number:

House Membership: (required)
Note: If you self-identify the incorrect House Membership, any potential offer will be rescinded.

Residence (if on campus now):
Room Number:

Permanent Mailing Address:


for 2019-2020
Academic Year

Check each term
you are
applying to work

Summer '19


Yes No

Fall '19


Yes No

Winter '20


Yes No

Spring '20


Yes No


(e.g., Hanover FSP in Fall, unsure about Winter Term, waiting to hear back about Internship in Spring, etc.)

Will you be able to check your Dartmouth email during your off terms? Yes No

Have you previously worked for the College? Yes No

If yes, which department and position?

Do you have a physical or medical condition that requires special housing?
Yes No

Note: If yes, please submit the "Special Needs" Housing application to the Housing Office by the due date. The due date and the form may be found at: http://attic.dartmouth.edu/~orl/housing/separate/medical.html

Section B: Candidate Information

This information is used purely for statistical purposes and is not considered in making hiring decisions.

Origin/Identity: (check all that apply)

How do you self-identify (optional):

Section C: Residential Living Options

Section D: Judicial and Academic Standing

Please answer the following questions about your current judicial and academic status. Note that it is your responsibility to inform us of any changes that occur to your status during the selection process as well as during your employment should you be hired.

Have you ever been convicted of a misdemeanor or felony?

Yes No

Are you currently subject to academic action at the warning, probation, or suspension level?

Yes No

Have you ever received College disciplinary sanctions (Suspension level or higher)?

Yes No

Have you ever received sanctions due to violations of the Housing or Good Samaritan policies?

Yes No

Have you ever received a First Alcohol Violation?

Yes No

If yes to any of these questions, please explain and include date(s) of conviction(s)/sanction(s)/academic action(s), the nature of the offense(s), and disposition of the case(s):

Note that answering yes to any of the above questions will not necessarily preclude employment. If you answered yes to a question, the circumstances may be discussed during the interview process. Factors such as the seriousness and nature of the violation, when and where it occurred, and subsequent behavior will be taken into account.

Section E: Additional Employment, Activities, Research, etc.

List any employment, extra-curricular activities (sports teams, campus organizations, Greek Letter Organizations and Societies, musical and/or performance groups etc) and/or research which you expect to pursue during the 2017-2018 academic year. List hours per week for each item listed.


Avg. Hours per Week

Please answer in 3-4 sentences: How do you see the UGA position and all of its responsibilities fitting into your current lifestyle? How might it challenge or enhance your current activities and responsibilities?


I certify that the information I have provided on my application is accurate and complete. I also understand that the Office of Residential Life may choose to discuss my candidacy with my Dean, other appropriate College officials, and/or consult my Dean's File as a means to further determine my suitability to serve as a staff member in the residence halls.

Yes No