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APPOINTMENT REQUEST FORM (Louisiana Tech University)

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APPOINTMENT REQUEST FORM
Non-Classified Personnel
New Appointment _____ (complete front & back)
Continuing Appointment _____ (complete front only) No. _________________
Amended Appointment _____ (complete front only) Date ________________
Graduate/Teaching Assistant Fee Waiver _____ Summer _____ Fall _____ Winter _____ Spring
INSTRUCTIONS
: Department Head, Dean, or other Budget Unit Head will initiate and retain one copy. Completed original form
should then be forwarded to appropriate offices for signature. Official transcripts for new
teaching faculty should accompany the original
appointment form. This form should be fully processed with complete
information prior to the effective date of employment. All new
appointments should be fully processed and have Board of Supervisor approval prior
to the effective date of employment. (Graduate and
Teaching Assistant appointments do not require Board of Supervisor approval.) Forms not received in the Office of Human Resources
by the 15
th
of the month will be processed the following month. The Office of Human Resources will forward a final approved copy
to appropriate unit(s). *If a blank does not apply type n/a.
Name _____________________________________________ Date Effective ___________________________
Last First Middle Social Security No. _______________________
Date of Birth ____________________________
Address ___________________________________________ ______ Male ______ Female
Local Street Address
Marital Status ___________________________
___________________________________________ Race ____________ Nationality ____________
City/State Zip Code VISA No. ______________________________
Educational Attainments
Degrees University Year Earned
Doctorate ________________________________________
Experience:
Master ________________________________________ Higher Education ____________________________
Years at Tech ____________________________
Bachelor ________________________________________ Other ____________________________
Total Experience ____________________________
Department ______________________________________ Requested Salary (Yr.) ________________________
Amount to be Paid ___________________________
Rank or Discipline _________________________________ Base Monthly
____ Full-Time
____ Replaces ________________________________ ____ Part-Time _________ (% Full-Time)
Salary Basis
: ______ 9-Mo. ______ 12-Mo. ______ Quarterly _____ Other _________________________
______ Released-time: ______ % Salary Charged to _____________________________________
(Grant or Contract & Code)
Retirement
: ______ Social Security ______ Teachers’ ______Employees’ ______ ORP ________________
Budget Page Total
Department Codes & Line No. % Monthly Amt. Time Periods Funds
Major ____________________ ___________ ______ ______________ ________________ ____________
Split ____________________ ___________ ______ ______________ ________________ ____________
Grant ____________________ ___________ ______ ______________ ________________ ____________
Grant ____________________ ___________ ______ ______________ ________________ ____________
Comments: __________________________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Requested________________________________ ________ ___________________________________ ________
Project Director (Grants Only) Date Budget Officer Date
________________________________ ________ ___________________________________ ________
Dept. or Budget Unit Head Date Division Head Date
________________________________ ________ ___________________________________ ________
Dean Date President Date
________________________________ ________ ___________________________________ ________
University Research (Grant Funds Only) Date Office of Human Resources Date
Form Completed by: ________________________________
Ext#: ________
(Please list in reverse order stating the
most recent experience first)
A. HIGHER EDUCATION EXPERIENCE DATES
University (or employer) Position of Service From To
B. OTHER EDUCATIONAL EXPERIENCE
Employer Position and Nature of Service From To
C. OTHER EXPERIENCE
1. Since Baccalaureate Degree
Employer Position and Nature of Service From To
2. Prior to Baccalaureate
-------------------------------------------------------------------------------------------------------------------------------------
SUMMARY EVALUATION
:
Total Years of Experience in Higher Education _______________
Of These, Years Applicable to Present Teaching Field _______________
All Other Experience _______________
Other Experience Applicable to Present Work _______________
TOTAL _______________
Evaluated By:
___________________________________________
Budget Unit Head
Concurred By:
___________________________________________ _________________________________________
Dean or Director Vice President
Credentials, Experience page,
and Transcipts on file._______
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Completed 23 July 2020

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