Fillable Get File Group Id 4202574 Filename POI Volunteer 2520 Form 10.31.17 BR (California Maritime Academy)

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Get File Group Id 4202574 Filename POI Volunteer 2520 Form 10.31.17 BR (California Maritime Academy)

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PERSON OF INTEREST (POI)/VOLUNTEER FORM
AUTHORIZATION – HR Initials:
Date:
POI Identification #:
The hiring department completes Section I and the volunteer completes Section II. The department is responsible for
sending the original to the Department of Human Resources. When the form is complete, and all signatures have been
obtained, the Department of Human Resources will authorize campus conveniences if eligible and requested. Incomplete
forms will not be accepted and will be returned to the Hiring Department for completion.
SECTION I: POSITION INFORMATION (TO BE COMPLETED BY HIRING DEPARTMENT)
DEPARTMENT INFORMATION
PLEASE SELECT:
☐ VOLUNTEER
REQUIRED FOR VOLUNTEERS: Statement Acknowledging Requirement to Report Child Abuse and Neglect
☐ PERSON OF INTEREST (POI)
☐ EMERITUS STAFF/FACULTY ☐ NAVAL ☐ CONSULTANT ☐ JANITORIAL ☐ FOLLET
☐ FOOD SERVICE ☐ ASCMA ☐ CHAPLAIN ☐ OTHER:
SPECIFY THE TYPE OF ACCESS NEEDED (IF ANY): ☐ OUTLOOK EMAIL/CALENDAR* ☐ MOODLE*
☐ COMPUTER/DRIVE ACCESS* ☐ WEB PAGES* ☐ PORT PASS* ☐ 25LIVE* ☐ OTHER:
Department:
Department ID:
Effective Date
(mo/day/yr):
Termination Date:
(mo/day/yr)**:
Reporting to:
Phone Number/Extension:
Assignment and Duty Summary:
1. Will Volunteer/POI work with minor children? ☐No ☐ Yes, Live Scan/Background Check Required
2. Will Volunteer/POI travel on university business? ☐No ☐ Yes, Complete Defensive Driver Training & Provide
Driver’s License Information:
Driver’s License #: Expiration Date:
3. Will Volunteer/POI drive a personal vehicle on university business? ☐No ☐ Yes, Please review Use of
University & Private Vehicles Guidelines and complete State of California Authorization to Use Privately Owned
Vehicle on State Business (STD. 261). Submit with POI/Volunteer Paperwork
4. Is Volunteer/POI a student, staff, or faculty member? ☐No ☐ Yes (ID #:_______________________)
5. Is Volunteer/POI under 18 years of age? ☐No ☐ Yes, Parental Consent Form Required
My signature below certifies that the above named POI/Volunteer requires system access and/or access to data in a
computer-based information system because such access is necessary in the ordinary course of fulfilling his/her
responsibilities to the university. I understand my obligation to ensure training is provided so that he/she understands
the state and federal laws and University policies that govern access to and use of information contained in employee,
applicant, and student records including data accessible through computer-based information systems.
Manager Signature: Date:
*IT FORMS REQUIRED: Computer/Email Usage Agreement and Account Access Form
**Termination Date must be NO MORE than three years from Effective Date
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PERSON OF INTEREST (POI)/VOLUNTEER FORM
AUTHORIZATION – HR Initials:
Date:
POI Identification #:
SECTION II: VOLUNTEER/POI COMPLETES “PERSONAL INFORMATION” SECTION.
PERSONAL INFORMATION
Name:
Address:
City/State/Zip:
Telephone #:
Emergency Contact:
Phone:
PROVIDE THE FOLLOWING INFORMATION IF REQUESTING SYSTEM ACCESS:
Social Security #:
Date of Birth (mm/dd/yy):
☐ I have completed and attached the Computer/Email Usage Agreement and Account Access Form
VOLUNTEERS ONLY: This is to acknowledge that I desire to volunteer my services, performing duties
similar to those listed above and that services rendered by me will be at the direction of the above named
supervisor. I will not be compensated for these services. Further, I understand that I serve at the
pleasure of my supervisor.
Volunteer Signature
Date
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Get File Group Id 4202574 Filename POI Volunteer 2520 Form 10.31.17 BR (California Maritime Academy)

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Completed 19 July 2020

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