Equal Opportunity Office

REQUEST FOR EXEMPTION

Faculty/Staff Recruitment

Submitted by: / Date:

Name and Title

Signature: / Phone Number:
Exemption For:
(Proposed Appointee) / Last Name / First Name / Middle Initial
College/Department: / Position Number:
Rank/Title:
If this is a new position, has it been approved through Human Resources? / Yes / No / N/A
Effective Date of Exemption (if applicable): / through
(mm/dd/yyyy) / (mm/dd/yyyy)

Exemption periods will be extended only in exceptional circumstances and with the approval of the responsible vice-president.

An exemption from the faculty/staff recruitment procedures is requested for the above individual for the following reason(s): (indicate all that apply)

Temporary non-renewable appointment of up to one year, including visiting faculty, visiting summer session appointments, acting positions and research assistants.
Postdoctoral trainee appointed as research associate, generally for not more than three years.
Research faculty position in which the individual named serves as principal or co-principal investigator of an approved research grant(s) that specifically designates extramural salary support.
Change in the title and/or responsibilities of a current employee where the change involves expanding or restructuring an existing position and not establishing a new position.
Appointment to a faculty rank and title, regardless of the length of term, without compensation or with pay that is nominal compared to the regular compensation of a similar position, e.g. honorific titles.
Part-time appointments of up to 50 percent. A part-time appointment may not be changed from 50 percent or less to greater than 50 percent without conducting a search.
An acting or interim appointment made in an exigency. An acting or interim appointment may not be changed to a permanent appointment without a search unless additional approvals are obtained from the Vice President or, where appropriate, the President. Acting or interim appointments will normally be for less than one year in duration.
Unique qualifications that make a search counter-productive. Documentation of the qualifications must be attached.

NOTE: The attached Background Check Release Form must be completed and attached for this exemption form to be processed.

Dean/AVPDateVice PresidentDate

______

Equal Opportunity OfficerDate

Eastern Kentucky University

Richmond, Kentucky

Release for Background Investigation

I authorize Eastern Kentucky University to make any and all necessary and appropriate investigations to verify the information provided within my application for employment and/or interview process, including national and state criminal records, educational credentials, and sex offender checks. References and other investigations obtained are done so in confidence and I understand that my rights to view any reference materials are waived.

All information obtained will be used in strict compliance with all provisions of the FCRA and the Americans with Disabilities Act and all other applicable law including federal and state equal opportunity laws and regulations.

I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation.

Applicant’s Name:
Other Names Used:
Applicant’s Physical Address:
City/ State/ Zip
Social Security Number:
Driver’s License Number and State:
Name as appears on Driver’s License:
Date of Birth:
NOTE: Date of Birth information is used ONLY by for verification of identity and is not used for any purpose by the employer.
Signature of Applicant:
Printed Name of Applicant:
Phone Number: / Date Signed:

Applicants must return signed form to hiring Department

TO BE COMPLETED BY DEPARTMENT:

Hiring Dept. / Position Title
Position # (if applicable) / Position Status (circle one): / Full or Part Time
Position Type (circle one): Faculty/ Staff/ Student Workstudy/ Graduate Asst./ Temporary Staff
Required Degree to be verified (faculty only) (please attach vitae):
Contact name and number with results:

Eastern Kentucky University is an Equal Opportunity/Affirmative Action Employer and Educational Institution

Updated on 11/15/2018