Non-Senate Academic Term Appointee Employment Form (UCI-AP-21)

Non-Senate Academic Term Appointee Employment Form

UCI-AP-21
Initial AppointmentRenewalRevision
Dean Delegated Action?*
JPF/SWR#
If WOS - no search is required. Enter WOS.
Appointee Information

This appointment is contingent upon establishing your employment eligibility as required by Federal Law, as well as, clearing an Employment Misconduct Disclosure review where you will be required to disclose any final administrative or judicial decisions within the last seven years determining that you committed any misconduct and provide information related to investigations and appeals. Please see your Departmental Personnel Coordinator for necessary documentation.
Appointee Information

This appointment is contingent upon establishing your employment eligibility as required by Federal Law. Please see your Departmental Personnel Coordinator for necessary documentation. This is a term appointment, which is self-terminating on the end date, and subject to the notice requirements of APM 137. NOTE: APM 137 does not apply to the following title codes: 2716—Non-Physician Clinical Intern/Clinical Psychology Intern, 2732—Post-MD Clinical Trainee, 2740—Non-Physician Clinical Trainee.
Name
Department
School
PI/Supervisor
Institution
Highest Degree
Degree Major
Date Received
Has the Appointee ever been employed by UCI?*

YesNo
Dates of Employment at UCI
For most recent job held at UCI.
Job Code Description held at UCI
UCI Department
Initial Appointment Information

This is a term appointment, which is self-terminating on the end date, and subject to the notice requirements of APM 137. NOTE: APM 137 does not apply to the following title codes: 2716—Non-Physician Clinical Intern/Clinical Psychology Intern, 2732—Post-MD Clinical Trainee, 2740—Non-Physician Clinical Trainee.
Job Code
Job Code Description
Step
Begin Date

MonthDayYear
End Date

MonthDayYear
ExemptOff-ScaleNon-ExemptWithout Salary
Please ensure that an Misconduct Disclosure and Authorization to Release form is completed before the appointment is approved.
Annual Base Salary
Salary Scale
Basis/Paid
Percent Time
Total Annual Salary
Monthly Rate
Current Appointment Information
Title code:
Title Name:
Step:
Begin Date: Date
End Date: Date
Off-Scale   WOS   Exempt   Non-Exempt

Current Salary Information:
Annual Base Salary:    Do not add "$" or ","
Salary Scale:
Basic Paid:
%Time (as decimal):
Total Annual Salary
Monthly Rate
New Appointment Information
Title code:
Title Name:
Step:
Begin Date: Date
End Date: Date
Off-Scale   WOS   Exempt   Non-Exempt

New Salary Information:
Annual Base Salary:    Do not add "$" or ","
Salary Scale:
Basic Paid:
%Time (as decimal):
Total Annual Salary
Monthly Rate
Account Information
General Responsibilities (see list)
Employee Acceptance
, the Department of is recommending you for an appointment as . is the person to who you report and with whom you should discuss matters related to your employment. If appointed to a visiting title and on leave, I attest that I am on an approved leave with the support of my institution for this appointment. We hope you will accept this appointment and look forward to your involvement with the University of California.
Employee's Signature
MonthDayYear
Date
Approvals
Please add all signatures after printing the form and saving it as a pdf document.
PI/Supervisor Signature
Printed Name
MonthDayYear
Date
Department Chair/Director Signature
Printed Name
MonthDayYear
Date
Dean Signature
Printed Name
MonthDayYear
Date
Vice Provost for Academic Personnel Signature
Printed Name
MonthDayYear
Date
UCI-AP-21 Updated 6/25
Should be Empty:

Non-Senate Academic Term Appointee Employment Form

Appointee Information