HR 1.35 VCAA:PR (rev. 3/05)
The University of North Carolina at Wilmington
PERSONNEL RECORD DATA SHEET
This form is used to certify credentials and is required when hiring a new EPA employee.

1. Individual Being Hired: _________________________________________________________
      (full name required)                       Last Name                                      First Name                                 Middle Name

2. Social Security Number: ________________________________________________________

3. Permanent Address: ___________________________________________________________
                                                 Street                                            City                                         State                 Zip

4. Telephone:  (Work) _____________________________  (Home) _________________________

5. Country of Citizenship: _________________________________________________________

If not a U. S. citizen, indicate type of Visa: ____________________  Expiration date: _____________

6. Place of Birth: _______________________________________ Birth Date: _________________

7. Next of Kin: _________________________ Relationship: _____________ Telephone: __________
                                     (full name)

8. Education:
    Degree             Year Received             Institution Granting Degree        CIP Code (Major Field)
(Go to this website to find CIP Code: http://www.uncw.edu/oir/, then click on "CIP Codes for New Faculty")

____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
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9. Teaching Experience:
                    Institution                                              Rank/Position                        Dates (e.g., 1990-1991)
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

10. Credentials Verification Statement:
North Carolina law requires notice to every applicant for state employment that willfully providing false or misleading information or failing to disclose relevant information shall be grounds for rejection of an application or later disciplinary action or criminal prosecution. Dismissal from employment shall be mandatory in any case in which a false or misleading representation is made in order to meet position qualifications. The employer is required by law to verify an applicant's representations about credentials and other qualifications relevant to employment. By executing this employment form, you authorize the release to The University of North Carolina at Wilmington of any document or information within the possession of a third party, such as an educational institution or licensing board, that may serve to verify representations made by you in this employment application.

_______________________________________________________________________        _________________
Signature of Individual Being Hired                                                                                Date
Attach a curriculum vitae and return signed form within ten days to the Office of the Provost & Vice Chancellor for Academic Affairs.