Umd Person Of Interest Form
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2UMD Person of Interest Form
BIOGRAPHICAL DETAILS
Name: _____________________, _________________, _________
Employee ID: ______________
Last Name
First Name
Middle Name
(If one exists)
(Legal name as it appears on Social Security Card)
ORGANIZATIONAL RELATIONSHIP
Affiliate
External Service Provider
Other Payee
Sponsored Account
(WOS)
(ex. ROTC, Non-empl Search Committee Member)
(UNS)
(E-mail)
CONTACT INFORMATION
Home Address: __________________________
Campus Address*: ________________________
__________________________
________________________
__________________________
________________________
________________________
E-mail*: ________________________________
(Mail Code)*
________________________
Home Phone*: ___________________________
Campus Phone*: _________________________
PERSON OF INTEREST HISTORY
Year in this Role:
Effective Date: ________________
Planned Exit Date: _______________
Yr 1
Yr 2
Yr 3
(Cannot exceed 1 year of effective date. Can be extended 2 times)
Status:
Department #: ________________
Department Name: _______________
Active
Inactive
AFFILIATE RELATIONSHIP DETAILS (Affiliates only)
Job Code: ______________________________
Department #: ___________________________
Track*:
TC: Teaching
CD: Community Docs
CS: Clinical Scholar
RS: Research
PERSON RELATIONSHIP DETAILS (External Service Provider only)
For non-employee (external user) Search Committee members, Search Commitee access is requested through the ARF process once the POI is created.
Business Title: ___________________________
Department #: ___________________________
Supervisor Empl ID: _______________________ Supervisor Name: ________________________
BIOGRAPHICS (Other Payee’s only)
Date of Birth: ____________________________
National ID: _____________________________
(Only if needed to setup ID)
(Only if ID does not exist)
Gender:
Male
Female
Highest Education Level: ___________________
ADDITIONAL PAY PANEL (Other Payee’s only)
Earnings
If needed, Combo Code Override
Earn Code
Eff Date
End Date
Rcd #: _______
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Position #: _____________
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Last Updated 4/11/16
*Optional
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Parent category: Business