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Exhibit 5-Applicant Clearinghouse Form

(SAMPLE FORM-CONTACT HUMAN RESOURCES FOR THESE FORMS) University System of Georgia

PART A POSITION VACANCY ANNOUNCEMENT __________________Date Posted (Office)

1. INSTITUTION: ___________________________________

2. LOCATION: __________________________________________________________________                                   College/Division/School           Department                  Branch Campus (if not main)

3. DESCRIPTION OF POSITION: Check if new ______

TITLE: __________________________________________ Position: ________________________

JOB CLASSIFICATION(S): __________________________ INSTITUTION: ____________________

POSITION: (Opt) ___________________________________

ANNUAL SALARY: _________________ CONTRACT PERIOD: ______________________

DISCIPLINE(S): ____________________________________________________________________

REQUIRED QUALIFICATIONS:

DEGREE(S) ___________________________ YEARS EXPERIENCE ____________

SPECIAL REQUIREMENTS: __________________________________________________________

_____________________________________________________________________________________

5. RECRUITMENT DATA:

APPLICATION DEADLINE: ___________________            __________________________________                                                                                                       Signature & Title of Person Responsible

POSITION STARTING DATE: ___________________         __________________________________                                                                                                        PhoneNumber

 

PART B POSITION FILLED ANNOUNCEMENT                _______________________Date Posted  (Office)

1. NAME: _______________________________ 5. S.S.# ____________________________________

2. SEX: Male Female                                         6. DATE POSITION FILLED:      ________________

3. ALIEN: No Yes                                                7. EMPLOYMENT EFFECTIVE:   _______________

4. RACE:

     1-White (Not of Hispanic Origin)                        8. APPLICANT LOCATED THROUGH APPLICANT                                                                                               CLEARINGHOUSE:             Yes

     2-Black (Not of Hispanic Origin)                                                                              No

     3-Hispanic CLEARINGHOUSE No

     4-Asian/Pacific Islander

     5-American Indian/Alaskan                             9. _____________________________________________

     6-Multiracial                                                              SIGNATURE