Affirmation Form

Name: _______________________________________________________________ Email Address: ________________________________________________________

Department: __________________________________________________________

Employment Eligibility

Only United States (U.S.) citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Yes No Are you legally authorized to work in the U.S.?

Federal law requires proof of right to work in the U.S. no later than three business days after the employment start date. Will you, now or in the future, require sponsorship for employment visa status (e.g., H-1B visa status)? Yes No

Do you have relatives who are currently employed by the University of Central Florida?* Yes No

If yes, please provide their name and relationship: ____________________________________________

*Please note that persons who intend to marry or with whom the employee intends to form a domestic partnership or other intimate relationship

are included in this definition of “relative.”

If currently or previously employed by the State of Florida or the State university, please specify where:

Background Information

All questions within this mandatory background section must be answered. Please note that a “yes” answer to these questions will

not automatically bar you from employment. The nature, job relatedness, severity, and date of the offense in relations to the

position for which you are applying are considered. 1) Are there any criminal charges now pending against you other than non-criminal traffic violations? Yes No

If yes, please state the charges, dates and locations: ________________________________________________________

________________________________________________________ 2) Have you ever been convicted in court of a felony or misdemeanor? Yes No By answering 'Yes' to the above question does not disqualify you from being considered for the position. If yes, please describe the charges, date of conviction, court location, and disposition. __________________________________________________________________________________________________ __________________________________________________________________________________________________

Applicant Acknowledgment

I hereby authorize the University of Central Florida to verify all information contained in this application and my supplement (s) hereto. I certify that all statements in

this application are true and complete. I further understand that any omissions, false statements, misstatement, or misrepresentations made by me on this

application, or my supplement(s) hereto, may be grounds for rejection from consideration for further employment or immediate discharge.

I acknowledge that in accordance with UCF Regulation 3.039, participation in the direct deposit program is mandatory. Employees will be required to complete a

direct deposit authorization form at the time of payroll sign-in. Also, employees of all Public Employers in the State of Florida are required to take an Oath of Loyalty

to the United States and the State of Florida.

I understand that OPS non-student employees will be enrolled in the mandatory UCF 401(a) FICA Alternative Plan. Please be advised that the FICA Alternative Plan is considered

to be a “tax qualified plan” for purposes of determining your ability to make before-tax contributions to an individual retirement account (“IRA”). If your total income (or, if

married and filing a joint return, the total income of you and your spouse) exceeds certain levels you may not be eligible to make before-tax contributions to an IRA due to your

participation in the FICA Alternative Plan. Accordingly, you may want to seek the advice of your individual tax advisor before making IRA contributions.

Any retiree with a retirement date of July 1, 2010 or later, must remain off the payroll for 6 full calendar months before they are eligible for rehire. Retirees who are

initially reemployed on or after July 1, 2010, will not be eligible to earn another retirement benefit. An individual is considered retired if he or she has received any

benefits under the FRS Pension Plan (including DROP) or has taken any distribution (including a rollover) from the FRS Investment Plan, or alternative retirement

programs offered by state universities (SUSORP), state community colleges (CCORP), state government (SMSOAP), or local governments (senior management).

Applicant Signature: _________________________________________________________________ Date: __________________________________