Form Uga Hr - Security Questionnaire -University System Of Georgia Page 2
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2NOTE: Before signing this form, check all answers and explanations to see that you have answered all questions fully and correctly. This form is to
be executed under oath subject to the penalties of false swearing as prescribed in Code Section 26-2402 of the Criminal Code of Georgia.
AFFIDAVIT OF VERIFICATION
State of _______________________________ County _______________________________
Indicate state & county where this document is being notarized.
Personally appeared before the undersigned attesting officer, duly authorized to administer oaths, ______________________________________
who, after being sworn, deposes and says and declares under penalties of false swearing that he or she is the person who executed the foregoing
instrument; that he or she has read and completed the same and knows and understands the contents thereof; that the matters stated therein and the
answers and information furnished by him or her in the foregoing questionnaire, including any attachments thereto, are true and correct.
SWORN TO AND SUBSCRIBED BEFORE ME ____________________________________________________________________________
(Signature of Employee)
This ___________ day of ________________________, _______________
month
year
____________________________________________________
Notary Public
County of ____________________________ My commission expires ________________ day of _______________________, _____________
month
year
(Affix seal)
INFORMATION TO BE FURNISHED BY EMPLOYING UNIT
INSTRUCTIONS TO UNIT: If this questionnaire is executed by applicant, insert “APPL” in the space for date of appointment, and show date of
application. If this questionnaire is executed by an individual who has been offered employment or who is already employed, provide the information
requested.
DATE OF
TITLE OF POSITION
UNIT AND DEPARTMENT
DUTY STATION
APPOINTMENT
(Ex: professor, secretary, etc.)
(First day of work)
(Ex: Athens, Griffin, Brunswick, etc.)
(Ex: Chemistry Dept., Univ. of Ga.)
Board of Regents
University System of Georgia
LOYALTY OATH
Indicate state & county of current residence
STATE OF ____________________________________________
COUNTY OF ________________________________________________
I, _____________________________________________________________, a citizen of ____________________________________________
(Permanent residence)
State
and being an employee of the University System of Georgia and the recipient of public funds for services rendered as such employee, do hereby
solemnly swear and affirm that I will support the Constitution of the United States and the Constitution of the State of Georgia.
This __________________day of ________________, __________
Signature of Employee
month
year
Sworn to and subscribed before me this day and year above set out.
________________________________________________
Notary Public
(Affix Seal)
Send this completed form to Records, Human Resources Building, 215 S. Jackson St. Athens, GA 30602
PLEASE NOTE THAT EACH OF THE ABOVE DOCUMENTS, THE SECURITY QUESTIONNAIRE AND THE LOYALTY OATH, MUST
BE SIGNED AND NOTARIZED.
UGA HR 11/07
Page 2
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