Sam Houston State University
Non-Compensated Affiliate Sam ID and Clearance Request
Requesting Department Contact: _______________________________________
Social Security Number: _____________________________________________
Full Legal Name:
First Middle Last
Date of Birth:
Email Address: ______________
Natural born U. S. Citizen
U.S. Phone: _____________
U.S. Mailing Address: ______________________
Permanent Resident Alien
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:
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.
Joseph Mesa (4-3347)
Charter School Volunteer
Complete and return to Joseph Mesa at email@example.com