SIMPREX LOGISTIC

COMPANY LOGO ______HR

Dept
EMPLOYMENT CONTRACT

To ,
Date
EMPLOYEE NAME
ADDRESS
Dear Mr

In response to your application and subsequent interview, we are pleased to offer you
employment in our organization on the following terms and conditions.

Job Position : OPERATIONS SUPERVISOR

Reporting to : Asst.Manager/Executive Manager

D.O.J : Upon Arrival in Qatar

Status : Single
Salary : QR.2500 ( 1750 +750) 70% Basic + 30% Allowances
Duty Hours : 12 hrs. Your duty timing needs to be flexible to suit the
operational requirements.
Duties & Responsibilities :
 SIMPREX LOGISTIC
LOCAL TRAVELING EXPENSES FORM
 
 
            This is to certify that I have maintaining a Car/Scooter/Motor Cycle bearing No.
____________________ which is registered in my name and is owned by me, in proper running
condition and have utilised the same in the performance of official duties.  Expenditure, wholly,
exclusively and necessarily incurred on the maintenance and running of the aforesaid vehicle in
connection with the official duties during the period from ______________ to
_________________ was in excess of Rs.___________ (Rupees
___________________________________ only).
 
 
                                                                        Signature :
                                                                        Name :
                                                                        Designation :
                                                                        Emp. No. :
Date :
Place :
 SIMPREX LOGISTIC
LOCAL CONVEYANCE CLAIM

NAME : EMPLOYEE ID :

DESIGNATION : DEPARTMENT :

FROM : TO :

S.NO DATE TIME FROM TO MODE DIST (KM) PURPOSE AMOUNT

 SIMPREX LOGISTIC
MOVEMENT FORM

S.No. Date Place to Visit From (Time) To(Time) Purpose Req. Approved By
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 SIMPREX LOGISTIC
REQUIREMENT FORM

DEPARTMENT

DESIGNATION

LOCATION

QUALIFICATION

DESIRED PROFILE

HEAD HUNTING

SPECIFIC INDUSTRY EXP

EXPERIENCE(NO. OF YEARS)

TARGET DATE ON BOAD

SALARY PACKAGE (ANNUAL)

MARKET SALARY RANGE

SPECIAL SKILLS

Proposed By Approved By

________________________
_________________________

For HR Use:
Position No.:
_____________________________________________________________________________________
Remark :
_______________________________________________________________________
 SIMPREX LOGISTIC Photograph
EMPLOYMENT APPLICATION
Position Applying For:
First Name Middle Name Last Name

Location:

PRESENT ADDRESS:
Street Address City, State & ZIP Employee ID (if applicable)

Home Phone Cell Phone Work Phone E-mail address

PERMANENT ADDRESS:
Street Address City, State & ZIP Employee ID (if applicable)

Home Phone Cell Phone Work Phone E-mail address

Do you have a Passport?  Yes  No If YES, Valid Till

Is your Passport ENCR Stamped?  Yes  No
Are there any Visa Rejections on your Passport?  Yes  No If Yes, provide details

Have you traveled overseas?  Yes  No If YES,

Are you 18 years of age or older?  Yes  No If NO, what is your current age?

Are you currently employed at Sigma or its Group  Yes  No If YES, what is your current job title & department?
Company?

Have you ever been employed by Sigma?  Yes  No If YES, dates of employment & reason for leaving:

Are you related to any current Sigma employee?  Yes  No If YES, their name & their relationship to you?
Do you have your own conveyance?  Yes  No If YES, What
Do you have a driving license ?  Yes  No If YES, State of issuance, license #, and expiration date:
How did you learn about this employment opportunity Sigma?

EDUCATION: (In reverse chronological order)/ Courses currently being pursued / Mention Gaps (if any)
Qualification Institute / University Subjects %age From To
High School

10+2

PROFESSIONAL / SHORT TERM COURSES:

Name of the Course Institute / University Subjects %Age From To

SKILLS
_________________________________________________________________________________
_________________________________________________________________________________
__________
LANGUAGE KNOWN:
S.No. Read Write Speak
1. English
2. Hindi
3.
4.

PERSONAL INFORMATION:
Date of Birth Marital Status:
Height Weight Eye Sight
Blood Pressure Blood Group Blood Sugar
Heart Problem  Yes  No
Have you ever been operated upon?  Yes  No
Preferred Doctor Doctor’s Ph. No.
Banker’s Name Bank Account No.

FAMILY BACKGROUND:
Relationship Status Profession/Occupation
Father
Mother
Spouse
Children 1
Children 2
Children 3
Brother/Sister 1
Brother/Sister 2
Brother/Sister 3
Any other Dependant

CURRENT COMPENSATION: Cost to Company p.a. (Attach salary slip / Bank record in support of the documentation, if not
available off hand the same may be produced later on joining)
Monthly Compensation Annual compensation

Basic PF:

HRA: LTA:

Conveyance: Medical:

Allow 1: Bonus:

Allow 2: Incentives:

Perks: Others:

TOTAL TOTAL

DETAILS OF THE CURRENT JOB :

_________________________________________________________________________________
_________________________________________________________________________________
__________
ORGANIZATION CHART (your position in the hierarchy)
1. Name of your group / division
_______________________________________________________________________________________
 2. Total number of employees in your group / division
______________________________________________________________________
3. Number of employees at your work
location____________________________________________________________________________

PLEASE DRAW TYOUR ORGANISATION CHART AND YOUR POSITION IN THE ORGANIZATION:

WORK EXPERIENCE-Please detail your entire work history. Begin with your current or most recent employer. If you held multiple
positions with the same organization, detail each position separately. Attach additional sheets if necessary. Omission of prior
employment may be considered falsification of information. Please explain any gaps in employment. Include full-time military or
volunteer commitments. PLEASE DO NOT complete this information with the notation “See Resume.” PLEASE NOTE: Sigma
reserves the right to contact all current and former employers for reference information.
Dates Employed (most recent position)  Full time  Part-time Title:
From:
______/______ to _____/______
mo yr mo yr
If part-time, # hrs./wk:
Starting Salary: Organization Name and Address:

Final Salary:

Supervisor’s Name, Title and Phone #: Other Reference Name, Title and Phone #: Contact my current references:
 At any time
 Only if I am a finalist candidate
Primary duties: Reason for Leaving

Dates Employed  Full time  Part-time Title:

From:
______/______ to _____/______
mo yr mo yr
If part-time, # hrs./wk:
Starting Salary: Organization Name and Address:

Final Salary:

Supervisor’s Name, Title and Phone #: Other Reference Name, Title and Phone # Contact these references:
At any time
Only if I am a finalist candidate
Primary duties: Reason for Leaving:

Dates Employed  Full time  Part-time Title:

From:
______/______ to _____/______
mo yr mo yr
If part-time, # hrs./wk:
Starting Salary: Organization Name and Address:

Final Salary:

Supervisor’s Name, Title and Phone Other Reference Name, Title and Phone Contact these references:
Number: Number: At any time
Only if I am a finalist candidate
Primary duties: Reason for Leaving

WHY WOULD YOU LIKE TO JOIN Sigma WEE Tech Corporation?

_________________________________________________________________________________
_________________________________________________________________________________
__________
REFERENCES: (At least 1 people you have worked under and 1 of relative)
 Name Address Designation/Company Contact (Phone/email)

JOINING TIME REQURIED:_________________week(s) DATE:

___________________________________
SIGNATURE: __________________________________________
 SIMPREX LOGISTIC
INTERVIEW EVALUATION SHEET (for office use only)
INTERVIEWED BY:

CRITERIA POOR AVERAGE ABOVE GOOD EXCELLENT

AVERAGE

Academic Background

Professional Knowledge

Experience & Exposure

Intelligence

Personality &
Communication
Leadership

Potential

Initiative & Drive

Team work

PRIMARY REMARKS:

INTERVIEWER’S SIGNATURE
SECONDARY REMARKS:

INTERVIEWER’S SIGNATURE
SUITABLE LATER REF. DATA BANK
UNSUITABLE STATUS 
  
DESIGNATION :

DEPARTMENT : REPORTING TO :

PROBATION PERIOD :

SALARY :

L.T.A. : GRADE :

ANY OTHER :

DATE OF JOINING : LOCATION :

 ( HR DEPARTMENT) (DEPARTMENT HEAD)
(DIRECTOR)

SIMPREX LOGISTIC
MEDICAL FORM
NAME :……………………………………………………............................ ID :
………………………………………………………..………

Date of Birth (dd/mm/yyyy) : ……………………………………………….. Age (yy/mm/dd) :

………………………………………………..

Blood Group: ……………………………… Height (in metres) :………………………………… Weight (in Kg) :
…………………………………..

Mediclaim / Accident Insurance (Yes/No) :………………………………. If Yes, Policy No. :

……………………………………………..

Emergency Contact

Doctor: Name:……………………………………………………………. Phone No.

………………………………………………………

Relative: Name:……………………………………………………………. Phone No.

………………………………………………..

Do you have a history of any of the following conditions? If so, please give details indicating frequency, severity and aggravating
factors where necessary, and any treatment you are taking (use extra pages if necessary)
YES/NO YEAR DETAILS
1. Any eye sight problem
2. Any hearing problem
3. Blood pressure
4. Heart or circulatory disease
5. Chest or lung disease
6. Asthma (if so, please give details of any
hospital treatment)
Hay fever
7. Travel sickness
8. Epilepsy
9. Diabetes
10. Digestive or bowel disorders
11. Past injuries (eg fractures, sprains)
12. Haematological or Blood disorders
13. Cerebral disease (eg stroke, head injuries
etc)
14. Metabolic or endocrinological disorders
15. Surgical operations
16. History of mental health problems
17. Allergies (dietary, drug, environmental)
18. Taking medication / suffering from medical
condition.
19. Special dietary requirements
20. Any illness or injury that might affect your
participation
21. Any activity in which you should not
participate
22. Suffering from any medical condition we
should know about
23. Any activities which may cause you physical
or mental stress
24. Received a tetanus injection in the last 5
years

If you have any other medical condition not disclosed above, please give details here:
Date: __________________________________ Signature:
_______________________________________
 SIMPREX LOGISTIC

Date : ………………..

SUB: JOINING REPORT

Dear Sir,

This has reference to the letter of appointment dated ……………..appointing me as

…………………………………………………………. in the organisation.

I hereby inform that I have joined my duty on ………………

As required by you, I am submitting the following documents for your records.

1. Date of Birth certificate

2. Educational certificate

3. Four passport size photographs

4. No objection certificate from the previous employer

5. Experience certificate

6. Residential proof.

7. Copy of passport (If Any).

8. Copy of driving License (If Any).

9. Proof of vehicle (If Any)

Thanking You,

Yours Faithfully
 SIMPREX LOGISTIC
PROBATION EVALUATION FORM - CONFIRMATION

NAME ………………………………………….. PERIOD UNDER REVIEW

………………………………
DESIGNATION ……………………………….. DIVISION
………………………………………………….
DATE OF JOINING……………………………. DEPARTMENT ……………………………………………
QUALIFICATIONS ……………………………. LOCATION
…………………………………………………
AGE…………………………………………….. TOTAL
EXPERIENCE…………………………………….

OUTSTANDING GOOD SATISFACTORY UNSATISFACTORY

QUALITY Always meets Meets predetermined Generally meets Consistently below
Level of accuracy in predetermined standards most of predetermined standard, needs
meeting standards under all thetime standards constant checking
predetermined conditions
standards
VOLUME Always meets the Most of the time meets Generally meets Consistently far
Quantity of work predetermined predetermined predetermined below the
based on standards of output standards of output standards of output predetermined
predetermined standards of output
standards
JOB KNOWLEDGE Has thorough and Well informed on all Acceptable knowledge Needs frequent
Knowledge needed indepth knowledge of aspects of own and of own job, but requires instructions, ability to
for own and related own, and related jobs related jobs. more training and assimilate varied
job; ability to grasp and very fast in Assimilation of experience; fair information poor.
concepts and issues, assimilation of varied concepts, issues good assimilation of
assimilation of varied information information
information
FORESIGHT & Is able to foresee all Is able to foresee most Able to foresee Unable to foresee
PLANNING critical problems and problems and plans problems of routine even problems of
Ability to foresee chalk out an advance advance action to nature and plans his routine nature. Lacks
likely problems and plan to avert crisis. Is defuse a crisis. Is able actions accordingly. planning ability and
plans accordingly to able to see clearly to stick to an action Deals with crisis as works from crise to
avoid working from through ambiguity and plan. they occur crisis
crisis. gives direction for
higher achievement

PROBLEM In all instances goes to In many instances goes Has ability to diagnose Unableto diagnose
SOLVING the core of the to the core of problems problems of routine correctly even
Ability to go to the problems and makes a and makes a correct nature. Needs to problems of routine
core of the problem correct diagnosis even diagnosis even in case improve skills to deal nature.
and to make a in case of problems of of problems of complex with problems of
decision based on complex complex.
correct diagnosis.
COMMUNICATION Always communicates Often communicates Generally Never communicates
Ability to convey and effectively, shares effectively shares communicates effectively, does not
receive oral and information with others information with others effectively, shares share information
written information. and provides timely and provides adequate information with others with others and
Effective sharing of feedback feedback and provides feedback provides feedback
 information and
providing feedback.

INTERPERSONAL Always cooperative and Cooperative most of the Generally cooperative Non-cooperative,
SKILLS does not create friction time and seldom and occasionally always creates
Degree of creates friction creates friction in friction in
cooperation, interpersonal relations. interpersonal
teamwork with relations
superiors and
subordinates and
other external stake
holders.
LEADERSHIP Always leads team Often leads team Generally leads team Never leads team
Effectively leads effectively by creating effectively by creating effectively by creating effectively by creating
team members by climate of trust, climate of trust climate of trust, climate of trust,
fostering openness, openness and openness and openness and openness and
trust and participative participative work participative work participative work participative work
work environment, environment. Never environment and environment and environment. Always
capability of depends upon formal seldom depends upon generally depends depends upon formal
influencing others authority. formal authority upon formal authority authority
without formal
authority
COMPANY Aware of Company Aware of Company Aware of Company Unaware of Company
PHILOSOPHY AND philosophy and philosophy and philosophy and philosophy and
OBJECTIVES objectives and identifies objectives and identifies objectives, identifies objectives and does
Level of awareness with them with them with some of them. not identify with them.
of Company
philosophy and
objectives, extent of
identification with
them.

ANY OTHER RELEVANT FACTORS (SPECIFY)

Appraisal Discussed with Mr / Ms :

Employee Reaction :

Appraiser's Recommendation :

Reviewer's Recommendation :

Appraiser’s Recommendation :

______________________________
____________________________
Appraiser's Signature / Date Reviewer's Signature /
Date
Action By HR Dept.
SIMPREX LOGISTIC
PERFORMANCE EVALUATION
DATE OF JOINING
ID & NAME

DEPARTMENT STATUS

REPORTING TO DESIGNATION
TOTAL WORKING P.L. C.L. S.L. ABSENT
APPRAISAL PERIOD DAYS

NO. PERFORMANCE FACTORS OS GD SR FR USR

1 JOB KNOWLEDGE / SKILL

2 QUALITY OF WORK

3 CAPABILITY UNDER STRESS

4 PUNCTUALITY & DISCIPLINE

5 COMMUNICATION & INTER-

PERSONAL SKILLS

6 CO-OPERATION & TEAM SPIRIT

7 COMMITMENT & SENSE OF

RESPONSIBILITY

8 PERSONAL APPEARANCE & BEARING

9 ATTITUDE TOWARDS SUPERIORS /

PEERS / SUBORDINATES

10 INTEGRITY

11 INITIATIVE DRIVE / DEPENDABILITY

12 PLANNING & ORGANIZING SKILL

13 DECISION MAKING ABILITY

14 EFFECTIVE INTELLIGENCE
ASSESSMENT SCALE
RATING SCORE DESCRIPTION
OUTSTANDING (OS) 91% - 100% Achievement of exceptional result consistently.

GOOD (GD) 81% - 90% Good performance where results surpass expectations.

SATISFACTORY (SR) 71% - 80% Acceptable performance which meets normal expectations.
FAIR (FR) 61% - 70% Marginal performance with occasional failure to achieve expected results.

UNSATISFACTORY BELOW 60% Unacceptable performance with frequent failure to meet expected results.
(USR)

Do you feel employee needs training in a specific

field_____________________________________________________________________________

__________________________________________________________________________________________________________________
______
 SELF EVALUATION
Write down your 08 (eight) job responsibilities or projects handled and rate yourself on a 05-point scale depending on how you feel
you are discharging each of these responsibilities.

NO. JOB RESPONSIBILITIES OS GD SR FR USR

Rate yourself according to the following characters:

NO. PERFORMANCE FACTORS OS GD SR FR USR

1 EFFECTIVE INTELLIGENCE

2 PERSONAL INTEGRITY

3 POTENTIAL FOR GROWTH

4 COMMUNICATION & INTER-

PERSONAL SKILLS

5 INITIATOR

6 CONTINUED SELF DEVELOPMENT

7 DECISION MAKER

8 PUNCTUALITY & DISCIPLINE

9 RELATIONSHIP WITH PEERS,

SUBORDINATES, CLIENTS

What is your contribution to the growth of the organization?

________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
______________
What suggestion do you have for the company?
_________________________________________________________________________
_____________________________________________________________________________________________
______

Date:___________________________
Signature:__________________________________
 SIMPREX LOGISTIC
LEAVE APPLICATION

ID : NAME : DESIGNATION :

TYPE OF LEAVE PERIOD TOTAL DAYS LEAVE REASON

ON LEAVE
P.L C.L. S.L. FROM TO

WITH PAY
WITHOUT PAY

ADDRESS WHILE ON PERSON

LEAVES DUE LEAVE/CONTACT TELEPHONE NO. RESPONSIBLE IN
ABSENCE

________________________ __________________________
________________
HR Department Recommended by
Sanctioned by

UNDERTAKING

I undertake that if I overstay on expiry of the sanctioned leave, I shall be marked as absent in my attendance register
and if I want to extend my leave, I shall intimate to HR department in due time and in the event of my illness, I shall
submit Medical Certificate from the appropriate Medical authority.

Signature of
Applicant
_____________________________________________________________________________________________
______

LEAVE CERTIFICATE
(To be retained by the Employee)

Certified that Mr./Ms._________________________has been granted PL/CL/SL

for_________days from_______________to_______________.
Reporting Date: ______________________

Remarks
:__________________________________________________________________________

Signature of HR
Department
 SIMPREX LOGISTIC
NO DUES CERTIFICATE
EMPLOYEE
ID
DESIGNATION

S.NO. DEPARTMENT SIGNATURE OF REMARKS

H.O.D.
1 Accounts
2 Projects
3 Business development
4 Contract
5 Office
6 Personnel
GENERAL
7 Visiting Cards
8 Mobile
9 Identity Card
10 Calculator
11 Computer Accessories
12 Any other

HAND OVER NOTE

NAME DESIGNATION DEPARTMENT
Name of employee
handing over
charge
Name of employee
taking over charge

List of documents handed over (use separate sheet, if necessary) :

1. List of Contracts-
2. List of Files-
3. List of Statutory Records & Registers-
4. List of Documents-
5. Any other-

__________________ ___________________ _________________

Signature of employee Signature of employee Approved by
handing over charge taking over charge

CC: Accounts Department - 1 Copy

HR Department - 1 Copy
Employee taking over charge - 1 Copy
Immediate superior - 1 Copy
HR/013/00

56
 SIMPREX LOGISTIC
FEEDBACK FORM

S.No. DESCRIPTION POOR FAIR GOOD EXCEL-LENT

1. Level of Satisfaction with
salary & Perks
2. Level of satisfaction with
hygienically factors like
seating arrangement, office
outlook, House keeping etc.
3. Attitude of senior colleagues

4. Organization Encourages
New Ideas/Experimenting.
5. My job offered me enough
opportunities to acquire new
competencies.
6. Seniors have the vision &
ability to guide the
organization through
environmental changes.
7. Organization had a faith in
my capabilities.
8. Communication between the
top management & employee
at all level.
9. Rewards are performance
based.
10. Matching of Personal
aspiration by organization.
11. Strengths of organization.

12. Areas needing improvement

& suggestions.

13. Suggestions

NAME : _____________________________ DEPATMENT :

_________________________
DESIGNATION : _____________________
 SIMPREX LOGISTIC
EMPLOYEE AUTHORIZATION FORM

Employee Details

Full Name: ___________________________________ Date of Birth: ________________

Social Security Number: _________________________ Job position __________________

Phone: _________________________________ Email: ____________________________

Address: ________________________________ Town: ____________________________

Zip: ______________________________  State: ____________________________

Authorizer details

Full Name: ___________________________________ Title: _______________________

Company: _____________________________ Designation ________________________

Phone: _________________________________ Email: ____________________________

Address: ________________________________ Town: ____________________________

Zip: ______________________________  State: ____________________________

I hereby authorize _____________________________ to employ the above named person on

powers bestowed to me by the state of ______________________ as a district parole officer.

Signature ___________________________ Date ___________________________

 SIMPREX LOGISTIC
NEW EMPLOYEE/NEW ASSIGNMENT PERSONAL DATA FORM

NAME _________________________________________________________
__________/__________/__________
LAST FIRST MI SOCIAL
SECURITY NUMBER
HOME ADDRESS
______________________________________________________________________________
_______________
Street City State
Zip
HOME PHONE ( )___________ CAMPUS PHONE __________ CAMPUS WORK
LOCATION

DATE OF BIRTH ______/______/______ GENDER ____ M ____F MARITAL

STATUS: ___ Married ____Single

VETERAN STATUS: YES/NO

IF YES, ____US Vet ____Disabled Vet ____Vietnam Vet ____ Retired Vet ____ Active
Reserve ______ Inactive Reserve

CITIZENSHIP STATUS
____ US ____ Naturalized Perm Resident Alien ________Visa Type
Citizenship
Expiration Date Expiration Date
Country ______________

ETHNIC CODE
C – White B – Black S – Hispanic/Spanish Surname O–
Other_________________
V – Cape Verdean R – Asian/Pacific Islander
A – American Indian/Alaskan
IN CASE OF EMERGENCY PLEASE NOTIFY:
Name _____________________________________Phone #
Relationship to Employee: ____________________
Address ___________________________________________City _____________________
State _____ Zip ______________
 I understand that this position is temporary. As a temporary employee, I understand that I
am not eligible for any benefits, unless otherwise indicated. UMass Dartmouth expressly
reserves the right to discontinue this appointment at any time without prior notice. In the
event of such discontinuance, I understand I shall receive compensation for work
performed to date. ELIGIBILITY FOR EMPLOYMENT MUST BE VERIFIED WITHIN
THREE DAYS OF EMPLOYMENT. THIS IS A CONDITION OF EMPLOYMENT.
Signature
_____________________________________________ Date _____________

TO BE COMPLETED BY THE DEPARTMENT HEAD/CHAIRPERSON:

Note: Temporary Positions are authorized on a fiscal year basis.
Title __________________________________________________ Department
Start Date ____________ End Date ____________ Bi-Weekly or Hourly Rate $
$ Amount Allocated Through June 30 th
$ Hours per week
st
$ Amount Allocated From July 1 to Appt End Date $ HR Account Code
Total $ Amount Allocated For This Appointment $ Proj/Grant Number____________________________
ESU Agency Fee? ___________Yes___________N
Authorized Signature ____________________________________ Date ______________

TO BE COMPLETED BY HUMAN RESOURCES:

HH Job Code HH Workgroup JJ Job Code JJ Workgroup
HH0100 Accountant HHSUBSAL HJ0400 Art Models JJSUBSAL
HH0300 Information Tech Professional HHSUBPOS HJ0500 Athletic Officials JJSUBPOS
HH0800 Artists HJ2000 Guides/Drivers
HH1200 Engineers HJ2500 Laboratory Services
HH1400 Health & Safety Experts HJ3300 Photographic Services
HH1600 Researchers/Post Doc HJ4600 Temp Clerical Services
HH1900 Management Consultant HJ5000 Instructor/Lecturer Trainer
HH2300 Program Coordinators HJ5800 Librarians/Archivists
HJ6109 Departmental Assistant
EMPL ID __________________ FTE ________________ DA2109 PTVL D_NBFAC
I-9 Date ___________________ Mail Drop ID _______________ DA2110 DCE Instructor D_NBFAC
Comments _______________________________________________

Guidelines for Emergency Hires

1. If vacant position that will be posted, then posting must take place within six (6) months.
 2. All emergency hires must have an EEO waiver that delineates the nature of the
emergency.

3. If not a vacant position, but a temporary emergency, then EEO waiver is still required
and the temporary appointment will be limited to less than one year and may not be
renewed without HR and EEO approval.

____EEO waiver received?

____Vacancy to be Posted?
____Temporary Emergency? (Not due to a vacancy)

This Section to be Completed by Human Resources

 Is this a bargaining unit position?

____Yes ______Faculty Federation ____ESU _____AFSCME

_____SEIU ____IBPO

_____No

 If ESU, Date of Union Notification _________________________

This Section to be Completed by Employee

ESU AGENCY FEE DEDUCTION AUTHORIZATION

I hereby authorize and direct the University of Massachusetts Board of Trustees, through its
officers, agents and employees, to deduct from the portion of my salary due me each month, the
amount as certified by the UMass Faculty Federation, Local l895, at the current rate of agency
fee (for non-members). Such deduction is to start immediately after the date of this
authorization.
I further authorize and direct you to transfer and pay the sum deducted to the Treasurer of the U
MASS Faculty Federation, Local l895, University of Massachusetts Dartmouth, North
Dartmouth, Massachusetts.

_______________________________
Signature

_____________________________
Date