EPA Faculty and Non Faculty - Nepotism Certificate

The University of North Carolina at Chapel Hill

Equal Opportunity/ADA Office

EPA Faculty and Non Faculty - Nepotism Certificate

This completed Nepotism Certificate is to notify you of a candidate being recommended for an appointment in the department who is related to another employee. This certificate also confirms the appointment will not result in a relative supervising or having any influence over the other relatives’ employment, salary administration or other related management, personnel considerations, or in any other violation of the subject policy on nepotism. The Nepotism certificate must be reviewed by the Equal Opportunity Office prior to any employee assignment or employment offer. You must submit a departmental organizational chart with your request.

PROPOSED APPOINTMENT

Name:
First / Middle / Last
Soc.Sec. Number : / xxx-xx-
Being Considered for:
Position / Position Number (for EPA Non-Faculty)
Reports To:
Print Name Classification Title

DEPARTMENT CERTIFICATION (If additional listings are necessary, attach on a separate sheet.)

Department:
Number / Name
The person proposed for appointment listed above is related to:
Name:
First / Middle / Last
PID #:
Position:
Position / Position Number (for EPA Non-Faculty)
Relationship (specify):

Print Name

This selection will not result in a relative (or closely identified person) supervising or having any influence over the other relative's employment, promotion, salary administration, or other related management or personnel considerations, or in any other violation of the subject policy. The department’s head or authorized representative must approve this form.

______

Signature of the Department Head or Authorized Department Representative Date

Name of Department Head or Authorized Department Representative

Attach Original form to: EPA Web New Employment Action.

Certification Review (to be completed by Equal Opportunity Office)

______

Signature of Equal Opportunity Officer Date

Ann E. Penn

Name of Equal Opportunity Officer

Rev. (06-03-2009) Equal Opportunity Employer Page 1 of 2