California State Employee Background Check - DOC by eru16792

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									California State University, Fresno                                                                       Human Resources
VOLUNTEER APPLICATION AND APPOINTMENT FORM
VOLUNTEER CRITERIA:
A volunteer is an individual who performs work or provides services for California State University, Fresno without pay. A volunteer
performs assigned duties under the direction and supervision of a faculty or staff employee, and must meet any license requirement s (i.e.
medical licenses, valid CA driver’s license, etc.) and CSU requirements for defensive driver training and a good driving re cord in order to
operate any State vehicle. Volunteers are covered by Worker’s Compensation Insurance and may be authorized to operate a Stat e vehicle.
Payment for nominal expenses may be made without jeopardizing the volunteer status. A state employee shall not volunteer within the
California State University for the same type of services they are normally paid to perform in the CSU.*


                         A. TO BE COMPLETED BY HIRING DEPARTMENT
CHECK ONE:                                                                CHECK ANY THAT APPLY:
    1) NEW VOLUNTEER ASSIGNMENT                                               Volunteer will be driving state vehicle
    2) EXTEND ASSIGNMENT (no break in service)                                Fingerprint check required
    3) REAPPOINTMENT (following break in service)                             Background check required
                                                                              ID card requested
                                                                              E-mail account requested
                                                                              Need to travel on University business
                                                                                       License      /      certificate          required:
__________________

VOLUNTEER STATUS - CHECK APPROPRIATE BOX:
   Current Fresno State Employee                                   Fresno State Emeritus               Fresno State Student
   Foundation/ASI/Athletic Corp Employee                           Community Member                    Other


College/School :                                                    Department :                                       Ext.: 8-
Volunteer Name :                                                    Class/Working Title :
Start Date :                                                        End Date ( DO NOT                 EXCEED END OF FISCAL
                                                                    YEAR*)
                                                                    Date ______________ or 6/30/20___
 Supervisor(s) Name & Title :                                        Ext: 8-
           DESCRIPTION OF DUTIES - MUST BE COMPLETED FOR ALL VOLUNTEERS




                  Complete For All Faculty and Academic Related Assignments
Courses being taught (list below):                                      Total WTU:


                                                 REQUIRED SIGNATURES
Department Head Signature:                                          Dean/Division              Head         Signature:            This
                                                                    appointment meets the                    vo lunteer       employee
                                                                    criteria as stated above.

Name and Title:                                                      Name and Title:

Date:                                                               Date:
* If appointment continues into the next fiscal year please attach additional form.
                                                            FOR HR USE ONLY
Dri ver F orms To:      Accounti ng : _ _ _ _ _ _ _ _ _ _ _ _            Ini ti al : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date Copi es sent to:   Documentati on: _ _ _ _ _ _ _ _ _ _ _ _          Department: _ _ _ _ _ _ _ _ _ _ _ _ _ _             Col l eg e/ School :
________
ID Card Issued:         Card # : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _   Issue Date: _ _ _ _ _ _ _ _ _ _ _ _ _ ___           Ini ti al s:
________________




                                 B. TO BE COMPLETED BY VOLUNTEER
Name (last, first, MI):
Mailing Address :                                                                                                      Home                 Telephone:(
                                                                                                                       )
City :                                                            State : CA           Zip :
         MUST BE COMPLETED FOR ALL FACULTY AND ACADEMIC RELATED VOLUNTEERS ONLY
Type of Degree :                                                                    Year Completed :
Institution Degree Received From :

1 . Have you ever been convicted for any offense, other than minor traffic violations?                                      NO              YES
    If YES, please explain :


2. Are you a U.S. Citizen?        YES         NO
    a. If NO, do you possess a visa with the appropriate work permit?                                YES                   NO
    Type of work permit:                                                                         Expiration Date:


    b. If YES, you are required to sign the Oath of Allegiance swearing (or affirming) your support of the Constitutions
of the United States and the State of California. Non-citizens are exempted, but you must complete PART 2,
Declaration of Permission to Work, of the Oath Statement .
3. Are you under 18 years old?             YES            If “yes” enter your date of birth: ______________
                                           NO.

4. Emergency contact information:
    Name of primary contact: ___________________________                                       Phone Nr.: (                ) _________        Relationship:
__________

   Name of alternate contact: __________________________                                      Phone Nr: (             ) _________             Relationship:
_________

*SIGNATURE OF VOLUNTEER : Thi s i s to ack nowl edg e that I desi re to vol unteer my servi ces to Cal i forni a State
Uni versi ty, F resno free of coerci on, threat or under i nfl uence b y any empl oyee of the Uni versi ty. I understand that I
wi l l not b e compensated for these servi ces. I hereb y certi fy that al l statements made on thi s appl i cati on are true
and compl ete to the b est of my k nowl edg e and b el i ef. I understand that fal si fi cati on of the ab ove record may b e
consi dered cause for termi nati on of the vol unteer assi g nment.

SIGNED:                                                                                                 DATE:


                              Declaration of Permission to Work ( non-ci ti zens onl y)
I am a l awful Permanent Resi dent Al i en of the Uni ted States.                      Y ES            NO
If NO, please read the following:
I hereby certify that I have permission to work in this country and have declared any restrictions placed upon me in this regard by the
United States government to the appointing power.

 *SIGNATURE OF VOLUNTEER:


*Reference cited: Fair Labor Standards Act Section 4(a&b)                                                              F orm   H R -V   –
9/ 05

								
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