Sam Houston State University
Non-Compensated Affiliate Sam ID and Clearance Request
Requesting Department:_____________________________________________
Requesting Department Contact: _______________________________________
Social Security Number: _____________________________________________
Full Legal Name:
First Middle Last
Date of Birth:
Email Address: ______________
Citizenship status:
Natural born U. S. Citizen
Naturalized Citizen
U.S. Phone: _____________
U.S. Mailing Address: ______________________
Non-Resident Alien
Permanent Resident Alien
2. Gender:
3. Are you Hispanic or Latino? Yes No
4. What is your ethnicity? Mark all that identify you:
American Indian or Alaska Native
Black or African American
Native Hawaiian or Pacific Islander
Reason for Non-Compensated Affiliate Request:
Visiting Scholar
Exchange Scholar
Other: _____________________________________
The HireRight Request will be sent to the email address provided on the top of this form.
After the HireRight Clearance is received, a SAM ID will be issued to create an Electronic Personnel Action Form (EPAF).
Non-Compensated Affiliates are typically set up for a maximum of one (1) calendar year at a time.
Non-Compensated Affiliates will need to complete required SHSU training.
The information provided by me in connection with this document is true and complete to the best of my knowledge.
Sam Houston State University is an Equal Employment Opportunity/Affirmative Action Plan Employer and Smoke/Drug-Free Workplace.
HRD 08/2017
Charter School
Joseph Mesa (4-3347)
Charter School Volunteer
Complete and return to Joseph Mesa at
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