Western Illinois University School of Graduate Studies
Graduate/Research/Teaching Support
Assistantship Contract Request
Budget number:
Date of Request:
Name of student:
WIU ID number:
Citizen of:
Graduate major:
Type of appointment:
Graduate Assistant
Teaching Support Assistant
Research Assistant
Intern (Peace Corps)
(Effective Fall 2012)
Stipend per month:
Number of work hours per week:
20 hours (full-time)
13 hours (2/3 time)
Other: ______%
Employment period:
Fall semester
Spring semester
Summer session
*If a fall/spring contract request is for less than 4-months, a justification must be attached and will require
review and consideration of the Director of Graduate School.
Please indicate specific begin and end dates, if not working from start of semester to end of semester:
List duties of position (be specific) and indicate percentage of time assigned to each duty. (Total should
equal 100%):
Name of supervisor:
Name of alternate supervisor (must be different individual than above):
Telephone directory information
Work address (Building/Room No./Office name, if applicable):
Work telephone number:
If work department is different than budget department, please enter the work department budget number
Fiscal agent (signature required): _________________________________________
Western Illinois University School of Graduate Studies
1 University Circle, Macomb, IL 61455-1390, Phone (309)298-1806; Fax (309)298-2345
Email: [email protected]
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