Revised 5/14/2018
University of North Georgia
MILITARY AFFILIATE INFORMATION FORM
(Please print legibly and provide all information requested)
Name: ______
Last First MI
SSN: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Date of Birth ______/______/_______ Male Female
(SSN and Date of Birth are required for access to university services and will not be used for any other purpose)
Permanent Street Address
_____
City State Zip Code
Email:
Home phone: ( __ __ __)
Mobile phone: ( _ _ _) __________________________________
Person to notify in emergency:
_______________________________
_
Name
__________________________
Phone
__________________________
Address
__________________________
Relationship
__________________________
Have you previously worked for the University of North Georgia? Yes No
If yes, what Department(s): Dates:
Will your duties as an unpaid affiliate include any programs or activities with nonenrolled minors? Yes No
Will your duties require you to have a UNG email account? Yes No
I attest that I am working as an affiliate to the University of North Georgia in my capacity as an active duty member
or a contract employee of the United States Army.
I agree to familiarize myself with, and abide by, the University of North Georgia rules and policies regarding conduct,
confidentiality, safety and welfare. I understand that I may be subject to the same pre-employment screening and
criminal background checks as UNG employees performing similar duties.
I understand that the State of Georgia provides general liability coverage to military affiliates, but no other university
or state-sponsored employee medical, retirement, workers compensation, or other insurance plans apply to this
association. I understand that UNG and I both have the right to end the affiliate relationship at any time, for any
reason, without advance notice.
I understand that if I am issued a university access card it is the property of the university and is issued at the
university’s sole discretion. I will not represent myself as a university employee, and I understand that the university
may revoke my access to its facilities and/or require that I return the card at any time for any reason.
My signature below affirms that all information on this information form is accurate to the best of my knowledge and I agree
to abide by the conditions outlined above.
Signature: ____________________________________________________ Date: ____/____/_____
Assignment Begin Date: ___/_______/_______ Assignment End Date:___/_______/______
(Note: All affiliate assignments are effective for the current fiscal year only, and may be terminated at any time.)
Department Name: _________________________________________
Department Head/Chair Name: ____________________________
Department Head/Chair Signature: __________________________ Date: ____/____/_____
This form must be forwarded to Human Resources after completion.
HR Review by: _______________________________________________________
BANNER #: ___________________________
HRMS ID #: ___________________________
UNG is committed to ensuring that this form is accessible to everyone. If you have any questions or
suggestions regarding the accessibility of this form, please contact Michael McLeod - 678.717.2232
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