Revised 5/14/2018
University of North Georgia
(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
Home phone: ( __ __ __)
Mobile phone: ( _ _ _) __________________________________
Person to notify in emergency:
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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