HR Affiliate Credential Form

HR AFFILIATE CREDENTIAL FORM

Personal Information

Date of Birth:    Phone:

Affiliate & Position Details

Proposed Start Date:    Anticipated End Date:

Contractor   Vendor   Academic Partner   Volunteer   Other:

Requested Access & Badge

Physical Building Access   Network / VPN Access   Application/Database Access   Restricted Data Access   Administrative Privileges

Photo ID Badge   Temporary Badge   Contractor Badge   Visitor Badge

I will complete all mandatory trainings and access-specific certifications prior to receiving credentials: Acknowledged

Employment History (Most recent first)

Education & Certifications

Professional References

Phone:   Email:   Relationship:

Phone:   Email:   Relationship:

Phone:   Email:   Relationship:

Background Check Authorization & Legal Disclosures

I authorize the organization and its agents to verify all information provided on this form, to contact prior employers and references, and to obtain background checks, criminal history records, and verification of credentials where permitted by law. I understand that credentialing and access are contingent upon satisfactory results.

By entering my last four digits of my Social Security Number I consent to limited use of that information solely for identity verification as part of background screening. The organization will retain such information only as permitted by applicable law and its data retention policies.

I consent to a criminal background check and employment verification as required for credentialing: Consent given

Legal Notices & Employment Status

At-Will: If the affiliate relationship is with an entity that has an employment relationship, such relationship is at-will unless a written agreement to the contrary is executed by authorized representatives. Neither this credential request nor any oral statements constitute a contract of employment.

Equal Opportunity: The organization is an equal opportunity provider and makes all credentialing decisions without unlawful discrimination. Selection for credentials is based on business need and security requirements.

Applicant Certification & Authorization

I certify that the information provided in this HR Affiliate Credential Form is true, complete, and accurate to the best of my knowledge. I understand that any false, omitted, or misleading information may result in denial of credentials or revocation of credentials and may subject me to disciplinary action.

I authorize the release of information about my employment, education, credentials, and background to the organization for the purpose of evaluating this application and administering access. I agree to comply with all organizational policies governing the use of issued credentials and to return credentials immediately upon request.

I certify and authorize as stated above

Emergency Contact

Relationship:   Phone:

Applicant Acknowledgement

By signing below I acknowledge I have read and understand the statements and authorizations above. I understand that issuance of credentials is a privilege conditioned on compliance with applicable policies and that privileges may be revoked at any time for failure to comply.

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