NAME:
1. Do you have prior USM (University of MD System)/State Agency service?
Yes No
If you answered “yes", please complete below all that apply. If you answered "no", skip steps 2 -4 and proceed to signature/date field.
2.
For what USM/State Agency did you work?
Please click on the link below to confirm that the Institution you selected above is part of the USM or an eligible State Agency.
List of Eligible USM/State Agencies
3.
Was any portion of your employment as (check all that apply):
Regular exempt
Regular non-exempt
Regular non-tenured faculty
Dates:
Dates:
Dates:
If “yes" to any of the bullets above, please be sure to provide dates of employment.
Note: These dates of employment DO count toward service time for leave purposes.
4.
Was any portion of your employment as (check all that apply):
Contingent I
Contingent II
Student Worker
Grad Assistant
Adjunct Faculty
Dates:
Dates:
Dates:
Dates:
Dates:
If you have answered “yes" to any of the bullets above, please note these dates of
employment do not count toward service time.
Name of the HR representative we can contact
to verify information you have provided
Business E-mail address of the HR representative
I understand that my service years and leave accruals are subject to validation by the USM/State Agency I have identified
above.
I am aware that no leave transfers/service year transfers will be granted to me until the information is confirmed by the
appropriate Agency.
I understand that not all leave may be eligible to be transferred to UMGC and that UMGC reserves the right to decline
certain leave type as deemed ineligible as per UMGC business practice.
(Please sign/date on the line below)
Accounting
of
Service
Time
for
Leave
Calculation
Purposes
