Biology Department Affiliate Request Form

Requester Name *

First Last

Requester Email *

Affiliate Name *

First Last

Affiliate Email *

Start Date *

MM

DD

YYYY

End Date *

MM

DD

YYYY

(Max One Year) You will be contacted one month before the status expires regarding renewal processes.

Is the affiliate a minor? *

Yes
No

Affiliate Type *

Affiliate Faculty: Non-BSU Employee serving on graduate committees
Regular Affiliate: Collaborating or volunteering w/ a university department

Detailed Roles and Responsibilities *

(e.g., job description, details of project(s) to be worked on, how anything related to this is funded)

Will this affiliate be receiving any type of funding from Boise State? If so what type? *

Compensation for Services to Boise State University
Stipend for Traineeship or other types of participation in university sponsored programs
Reimbursement for approved expenses associated to their collaboration w/ Boise State
Non-U.S. sources of funding
None of the above

Are there any non-U.S. sources of funding, research support, obligations, or the like involved in this affiliation? *

What funding sources? *

Additional Affiliate Services *

Please select all that apply:

Bronco Card – $30
Computer/Email Accounts
Recreation Center Access
Facility Access
Library Services
Temporary Campus Housing
Other

Will this be paid by the affiliate or with a university funding source? *

Paid at the Info Desk (by Affiliate)
University Funding Source
Affiliate already has a Bronco Card (used within the last two years)

Funding Source *

Please provide a Boise State funding source: xxxx.xxxxx.xxxxxxx (and project number, if applicable)

HR Background Information

Will this Affiliate/Visitor supervise, or interact regularly, with vulnerable individuals or minors under 16? *

Yes
No

Will this Affiliate/Visitor have direct access to, or control of, cash, checks, credit card account information, or personally-identifiable information which might enable identity theft? *

Yes
No

Will this Affiliate/Visitor possess a building master key(s), access to laboratory facilities, access to regulated facilities, or access to dorms? *

Yes
No

Please list any buildings on campus that you are requesting that this individual receives access to (and any special times being provided access to those buildings/labs)? *

Will this Affiliate/Visitor operate University-owned, -leased, or -controlled vehicles? *

Yes
No

Will this Affiliate/Visitor have direct access to, or responsibility for, controlled substances or hazardous materials? *

Yes
No

Will this Affiliate/Visitor have any special access to data or electronic resources being provided? *

Yes
No

Additional Comments

Use this field to provide any additional information to consider or take note of while processing this affiliate submission.

Biology Department Affiliate Request Form

HR Background Information

Department of Biological Sciences