Student Groove Card

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About the Groove Card FAQ Campus Representative FAQ

Campus Representative Application

Part A

First Name:
Last Name:
Street Address:
Street Address 2 (opt):
City:
State/Province:
Zip:
Home Phone #:	()- -
Cell Phone #:	()- -
Email:
Date of Birth:	/ / (mm/dd/yyyy)
Gender:	Male Female

Year in School:
Anticipated Date of Graduation:
How often do you check your email?:

What method of transportation will you be using to get to the stores? (Click all that apply):

	I will drive		Parent will drive me
	Walking		Bicycle
	Motorcycle/Moped		Public Bus
	Train/Subway		Other

Do you currently have a job?:

Yes No

	If yes, approximately how many hours per week do you work?:

What type of extracurricular activities are you involved in?
(Click all that apply):

	None		Fraternity/Sorority
	Student Government		Student Newspaper
	Sports		Radio Station
	Business Club		Music/Band
	Community Service		Debate Team
	Art		Education Club
	Drama/Theater		Other

How would you describe your grades in school?:
How did you hear about Student Groove Card™?:

Why do you want to become a Campus Representative?:

List 3 reasons why you believe that you would be a successful Campus Representative:

1.
2.
3.

Please share any additional information you would like us to know about you (optional):

Part B

Your School Name:
City:
State:
Zip:

**In addition to the students at your school, are there students from schools nearby who would use the Student Groove Card™ that you develop? Below, please list any colleges, universities, or graduate schools nearby.**

School Names	1.
	2.
	3.
	4.
	5.

Upload your resume (optional):