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E7 8 0 F8 1 R = ( = 1 = I 1 \ % v & T , t& D & % % % [7 [7 * % % % F8 ' ' ' ' = % % % % % % % % % : * * T O B E C O M P L E T E D B Y A P P O I N T M E N T D E P A R T M E N T * * A p p o i n t e e s F u l l N a m e : F O R M T E X T P r i m a r y R a n k T i t l e : F O R M T E X T B a s e D e p a r t m e n t N a m e : F O R M T E X T U N C P I D N u m b e r : F O R M T E X T
* * D E M O G R A P H I C D A T A T O B E C O M P L E T E D B Y A P P O I N T E E * * A d d r e s s : F O R M T E X T D a t e o f B i r t h : F O R M T E X T R a c e / E t h n i c i t y : F O R M D R O P D O W N G e n d e r : F O R M D R O P D O W N A r e y o u r e l a t e d b y b l o o d o r m a r r i a g e t o a n y p e r s o n n o w e m p l o y e d b y t h e U n i v e r s i t y o f N o r t h C a r o l i n a a t C h a p e l H i l l ?
F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o I f Y e s , p l e a s e p r o v i d e n a m e , r e l a t i o n s h i p , a n d d e p a r t m e n t n a m e o f t h i s i n d i v i d u a l :
F O R M T E X T E D U C A T I O N N a m e a n d L o c a t i o n o f C o l l e g e o r U n i v e r s i t y D e g r e e , D i p l o m a , o r C e r t i f i c a t e D a t e C o n f e r r e d M a j o r B a c c a l a u r e a t e F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T G r a d u a t e o r P r o f e s s i o n a l F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T O t h e r F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T E X P E R I E N C E N a m e o f E m p l o y e r R a n k o r T i t l e D a t e s o f E m p l o y m e n t C u r r e n t F O R M T E X T F O R M T E X T F O R M T E X T P r e v i o u s F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T A t t a c h a l i s t o f t h e f o l l o w i n g t o t h i s f o r m : ( a ) o t h e r p o s t - d e g r e e p r o f e s s i o n a l e x p e r i e n c e a n d a c t i v i t i e s ; ( b ) m e m b e r s h i p s i n s c h o l a r l y a n d p r o f e s s i o n a l o rganizations, and (c) publications. For item (c): Categorize publications under the following headings and list the inclusive page numbers, authors (in actual order), and publication (or in press) dates: Book, Book Chapter, Book Review, Dissertation, Monograph, Refereed Article, Other Article, Published Note or Abstract. For Refereed Article, if in press, in addition to the above information, list the target publication date. Also, if the article has been submitted and/or accepted for publication, list the n u m b e r o f m a n u s c r i p t p a g e s a n d d a t e s u b m i t t e d a n d / o r a c c e p t e d . L i s t s a t t a c h e d : F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
A p p o i n t e e I n i t i a l s : _ _ _ _ _ _ D a t e : _ _ _ _ _ _
A p p o i n t e e s F u l l N a m e : F O R M T E X T U N C P I D N u m b e r : F O R M T E X T
* * C E R T I F I C A T I O N S A N D C O N D I T I O N S O F E M P L O Y M E N T F O R T H E A P P O I N T E E * *
I n o r d e r t o r e c e i v e a n a p p o i n t m e n t w i t h t h e U n i v e r s i t y o f N o r t h C a r o l i n a a t C h a p e l H i l l , y o u m u s t a g r e e t o t h e f o l l o w i n g c o n d i t i o n s o f e m p l o y m e n t :
F e deral law requires each new employee to complete the Employee Information and Verification section of the Federal Immigration Service Form I-9 and to submit certain original documents for examination in order to verify and certify identification and employment eligibility. The University requires the completion of these requirements no later than three (3) business days of the employees first day of work counting the first day.
In compliance with North Carolina law, the University verifies each employees legal status or authorization to work in the United States after hiring using the Department of Homeland Securitys Basic Pilot Program. Your employment will be terminated if you fail to comply with the employment authorization requirements or if it is determined that you are not authorized to work in the United States.
North Carolina law requires notice to every applicant for state employment that willfully providing false or misleading information or failing to disclose relevant information shall be grounds for rejection of an application or later disciplinary action or criminal prosecution. Dismissal from employment shall be mandatory in any case in which a false or misleading representation is made in order to meet position qualifications. The employer is required by law to verify an applicant's representations about credentials and other qualifications relevant to employment. By executing this document, you authorize the release to The University of North Carolina at Chapel Hill of any document or information within the possession of a third party, such as an educational institution or licensure board, that may serve to verify any representations made by you on this Form AP2s.
The University requires all of its employees hired on or after July 1, 1999 to be paid by direct deposit into a bank or credit union account. In order to satisfy this requirement, you understand you must submit the direct payroll deposit authorization (Form PR-8) to the University Payroll Department by the end of your first workweek. Your signature below certifies that you understand you will not receive a paycheck from the University until the appropriate payroll forms have been completed and submitted.
You understand that you are required to provide your U.S. Social Security Number (if one has been issued to you) so the University can satisfy its income-reporting and withholding obligations under North Carolina and federal laws. Unless this sentence is marked through and initialed by you, you voluntarily permit the use of your social security number for internal record keeping and information management operations. However, you understand you will be randomly assigned a University-generated personal identification number (PID) which the University will instead use whenever possible.
You understand, if your positions duties expose you to blood borne pathogens or other potentially infectious material, you are required to attend the University Environment, Health & Safety Offices OSHA-required training within your first 10 days at work. You also understand that to comply with University policy, if your position's duties include engaging in University health care activities, you must (a) satisfactorily complete a tuberculosis screening skin test (PPD) within your first 10 days of work, and (b) disclose to your department head, dean, division chief, Office of the Provost, or the chair of the Universitys A.I.D.S. Task Force if you are currently, or later become, infected with either the HIV or Hepatitis B viruses.
Appointee Initials: _ _ _ _ _ _ _ _ D a t e : _ _ _ _ _ _
A p p o i n t e e s F u l l N a m e : F O R M T E X T U N C P I D N u m b e r : F O R M T E X T
C o n s i s t e n t w i t h a n y a p p l i c a b l e w a g e - h o u r l a w s , y o u a u t h o r i z e t h e U n i v e r s i t y t o w i t h h o l d f r o m y o u r f i n a l p a y c h e c k t h e cost of any State-owned property you fail to return when your appointment ends. You also authorize the University to withhold from your final paycheck the amount of any other debt you owe to the University.
North Carolina law requires certification that you are in compliance with the registration requirements of the Military Selective Service Act ( HYPERLINK "http://www.sss.gov/must.htm" http://www.sss.gov/must.htm) prior to employment. The University is required by law to verify such compliance.
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l a ytc you do not answer affirmatively to either Question A, B or C listed below, you will be notified that a proposed finding of ineligibility for employment will be finalized, unless, within 30 days, you provide information which establishes compliance with the registration requirements of the Military Selective Service Act.
(Check A, B, or C)
FORMCHECKBOX A. I certify that I am registered with Selective Service.
FORMCHECKBOX B. I certify that I am not required to be registered with the Selective Service because (select one):
FORMCHECKBOX I am a female. FORMCHECKBOX I am under the age of eighteen years.
FORMCHECKBOX I was born before 1960 FORMCHECKBOX I am a non-immigrant alien.
FORMCHECKBOX I am in the armed services on active duty (Reserves and National Guard are not considered on active duty.)
FORMCHECKBOX I am a permanent resident of the Trust Territory of the Pacific Islands or Northern Mariana Islands.
FORMCHECKBOX C. I certify that my requirement to be registered with the Selective Service has expired or is inapplicable, and (select one):
FORMCHECKBOX I was registered when the requirement was applicable to me.
FORMCHECKBOX I was not registered when the requirement was applicable to me, but my failure to register was not a knowing and willful failure to register. Please explain on attached signed and dated sheet.
Appointees Signature: ___________________________________ Date: ___________________
Appointing Department
Representative Signature: ___________________________________ Date: ___________________
The University of North Carolina at Chapel Hill
EPA STUDENT EMPLOYEE
CERTIFICATIONS AND CONDITIONS OF EMPLOYMENT
(Page PAGE 1 of 3 Pages)
Revised 05/16/07 Form AP-2s (Student)
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