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- Supplementalapptinfo 9-2016 (University of Michigan - Ann Arbor)

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A
Pg#1#of#2
"
SUPPLEMENTAL"APPOINTMENT
"
!"#$
"
%&'()**
%&'()**
"
To"be"completed"by"all"newly
appointed"faculty"and"staff.
INFORMATION
"
+!"#$,-"./01.2"
34.21/154,60/07
"
6",89:,;$01<
"
Revised"1/2019
"
Available"at:"hr.umich.edu/
human-resources-administrative-forms
Last"Name:
"
First"Name:"
Middle"Name:"
UMID:
"
ADDITIONAL(PERSONAL(INFORMATION"
Social"Security"Number:"
Month"of"Birth:"
Day"of"Birth:"
Year"of"Birth:"
Gender:"
Male" "
Female
"
Number"and"Street:"
City:"
State:
"
Zip"Code:"
Country:"
Telephone:"
Person"to"be"contacted"in"case"of"emergency:"
Emergency"Contact"Telephone:"
Are(you(a(U.S.(Citizen?(
Yes(
No(
+=>,?8"@A,B<4024,C"$B<4/4,
24C/1".,
D4<"EF7"
NON-CITIZENS(OF(THE(UNITED(STATES(OF(AMERICA(-"
Appointees#who#are#not#
citizens#
of#the#U.S.#must#
complete#the#following#section."
I"
certify"
that"I"am"a"
citizen"
of"
the"country"of:
"
Have"you"been"granted"permanent"
residency"status? "
"""""""""""""""""Yes" """
No
"
Complete"the"“Alien"
Certificate”"
form"on"the"following"website:" h
tt
p://www
.
fi
nance.umich.edu/
fi
nops/pa
yr
oll/"
forms/alien"certificate"
to"assist"the"Payroll"Office"in"properly"administeri ng"tax"regulations.
"
If"residency"status"has"not"been"granted,"please"indicate"type"of"visa"below." (If"“Other”"is"checked,"please"provide"details"in"Remarks.)"
F-1"
J-2"
0-1"
Other"
J-1
H-1B
TN
"
EMPLOYEE(OATH"
By"signing"below,"you"are"swearing"or"affirmin g"to"the"following"oath."
In"order"to"be"employed"by"the"University"of"Michigan,"state"law"and"Regent’s"bylaw"2.15"requires"that"you"execute"the"following"oath:" “I"do"
solemnly"swear"(or"affirm)"that"I"will"support"the"
Constitution"
of"the"State"of"Michigan,"and"that"I"will"faithfully"discharge"the"
duties"
of"my"
position"
and"subsequent"
positions,"
according"to"the"best"of"my"ability.”"
INTELLECTUAL(PROPERTY(ASSIGNMENTS"
By"signing"below,"I"agree"to"the"following:"
As"part"of"my"
obligations"
under"Bylaw"3.10,"I"hereby"assign"to"the"Regents"of"the"University"of"Michigan"(“University”)"all"right,"
title,"
and"interest"in"
patent"rights"in"
inventions"
made"(e.g.,"conceived"or"first"reduced"to"
practice)"
by"me"as"a"University"employee"with"the"direct"or"indirect"support"of"
funds"administered"by"the"University"(e.g.,"through"the"use"of"University"resources"or"
facilities)"
regardless"of"the"source"of"such"funds."
I"hereby"accept"th e"transfer"of"copyright—from"the"University"to"me—of"the"scholarly"works"I"author"in"accordance"with"
SPG"601.28"and"as"it"may"be"changed"from"
time"
to"time.
"
Adherence(to(these(terms(and(all(Regents’(policies,(as(they(are(from(
time(
to(
time(
amended,(is(a(
condition(
of(
continued(
employment(at(the(
University(of(Michigan.( Do(you(agree(to(the(conditions(stated(above?
Employee(Signature:"
Date:
"
Remarks:
"
If completing this form because of a rehire or change, please fax to 763-1283.
Revised"5/2018
"
Available"at:"hr.umich.edu/human-resources-administrative-forms
"
A
Pg#2#of#2
"
Do,NOT,Email
"
Form"
SUPPLEMENTAL(APPOINTMENT(INFORMATION
"
To"be"completed"by"all"newly
"
HR36100
HR36100
"
ETHNICITY/RACE
"
"
appointed"faculty"and"staff."
(Form,Contains"
Sensitive,Data)
"
Last"Name:"
First"Name:"
Middle"Name:"
UMID:"
Department:"
ETHNICITY/RACE"
To"meet"government"requirements,"the"University"of"Michigan"places"ethnicity/race"data"into"its
"
computer"file"for"
statistical"
use." The"data"will"be"used"to"meet"
reporting"
requirements"and"other
"
requirements"outlined"in"the"University’s"
Affirmative"Action"
Program." The"
information"
requested"in
"
items"1"and"2"below"is"
o ptional"
and"will"not"be"used"for"hiring"purposes.
"
1. Please(indicate(whether(you(consider(yourself(to(be(Hispanic(or(Latino.
No,(not"Hispanic"or"Latino."
Yes,(Hispanic"or"Latino:" A"person"of"Cuban,"Mexican,"Chicano,"Puerto"Rican,"South"or"Central"American,"or"other"Spanish"
culture"or"origin,"regardless"of"race."
2. In(
addition,(
select(one(or(more(of(the(follow ing(racial(categories(to(describe(yourself:
American(Indian(or(Alaska(Native:(A"person"having"origins"in"any"of"the"original"peoples"of"North"and"South"America"
(including"Central"America),"and"who"maintains"tribal"
affiliation"
or"community"a
tt
achment.
"
Asian:( A"person"having"origins"in"any"of"the"original"peoples"of"the"Far"East,"Southeast"Asia,"or"the"Indian"subcontinent"
including,"for"example,"Cambodia,"China,"India,"Japan,"Korea,"Malaysia,"Pakistan,"the"Philippine"Islands,"Thailand ,"an d "
Vietnam."
Black(or(African(American:( A"person"having"origins"in"any"of"the"black"racial"groups"of"Africa."
Native(
Hawaiian(or(Other(Pacific(Islander:( A"person"having"origins"in"any"of"the"original"peoples"of"Hawaii,"Guam,"
Samoa,"or"other"Pacific"Islands."
White:( A"person"having"origins"in"any"of"the"original"peoples"of"Europe,"the"Middle"East,"or"North"Africa."
Employee(Signature:"
Date:
"
If completing this form because of a rehire or change, please fax to 763-1283.
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- Supplementalapptinfo 9-2016 (University of Michigan - Ann Arbor)

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Completed 12 February 2022

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