Central Connecticut State University
Recommendation for
University Assistant Appointment
Fiscal Year 2017-2018
Renewal _______ New Appointment_______
CCSU ID#
|___|___|___|___|___|___|___|___|
Name: ______________________
_______________________________________________________
Last First MI
Address: _____________________
________________________________________________________
Street
________________________________
_____________________________________________
City State Zip Code
Home #: (__________) _________
_- ___________ Cell #: (________) __________ - _____________
Department: _______________________________ Supervisor: __________________________________
Duties: _____________________
______________________________________________________________
___________________________________________________________________________________
Please use either # 1 or 2 1. If working full fiscal year 2. If working partial fiscal year
Start Date 06/23/2017 Start Date ____/____/____
Position #: |___|___|___|___|___| End Date 07/05/2018 End Date ____/____/____
Banner Index: |___|___|___|___|___|___| Total Weeks: 52 Total Weeks: _________ Total
Salary for 2016-17 Employment Period:
$_________ (rate/hour) x _________ (hours/week)* x __________ (total weeks) = $________________
*The number of hours assi
gned and worked by the University Assistant may not exceed an average
of 19 hours per week for the term of the employment. Hours worked may not exceed 40 hours per pay week.
Recommended by ___________________________________ (Supervisor) Date ___________
Print name / Signature
Approved by ________________________________________ (Dean, Director, etc.) Date ___________
Print name / Signature
Approved by ________________________________________ (Executive Officer) Date ___________
Print name / Signature
Approved by ________________________________________ (Grants-for ALL Grants) Date ___________
Print name / Signature
New appointments ONLY:
(To be filled in after appointment is approved) Date of Birth _____/______/______ Race ______ Sex M / F
For Human Resources Use Only
Human Resources Received _______
Citizen Y / N W-4 ____ CT W-4 ____ Ethics/Violence Prevention Policy _______
If No VISA or PRA I-9 ______ BKGRD _______ Employee # _________
Revised 04/26/2017