The UMMC employee who has agreed to serve as a sponsor will receive this information once you have submitted the form. The UMMC employee who has agreed
to serve as a sponsor will utilize this information to submit a UMMC non-employee request and will provide you with further instructions. You are not authorized
to engage with the institution until notified by your sponsor that the request has been approved and that all UMMC onboarding requirements and procedures are
complete (i.e., Student Employee Health review, compliance training, information security agreement, criminal history clearance, badging,
and educational observer forms if applicable).
Non-Employee Information
* First Name:
Middle Name:
* Last Name:
Preferred First Name:
Other Names Used:
* Driver's License/State ID Number:
* Driver's License State (select other for non-US residents):
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Distict of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
* Passport Number (if no Driver's License/State ID):
* Date of Birth (MM/DD/YYYY):
* Primary Phone:
Secondary Phone:
Cell Phone for ALERT U Emergency Notifications (On Campus Only):
* Address:
* City:
* State (select other for non-US residents):
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Distict of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
* Zip:
* Country:
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of The
Cook Islands
Costa Rica
Cote D ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic Peoples Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao Peoples Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and The Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
* Email Address:
Choose one if employed with any of the following companies:
Aramark
Crown Healthcare Laundry Services
HHS Environmental Services
Medical Solutions
Sadiant
* Are you currently on visa or in need of visa sponsorship?
Yes
No
* Are you a former UMMC employee or student?
Yes
No
* Are you a current UMMC employee or student in Workday?
Yes
No
* If Yes, Employee or Student ID Number:
* Age Range:
15 Years or Younger
16 To 17 Years
18 Years Or Older
* Is this for participation as an educational observer to shadow at UMMC?
Yes
No
* Please review the
Educational Observer Authorization and Attestation .
I acknowledge that I have read, understood, and agree to abide by the Educational Observer Authorization and Attestation.
* Educational observers less than 18 years of age must have written consent of their parents/legal guardians and review, sign, and upload the
Educational Observer Authorization and Attestation .
* Is this for educational credit at a school in which you are currently enrolled?
Yes
No
N/A
* UMMC Sponsor Name:
* UMMC Sponsor Email:
@umc.edu
Additional Information
* Please review the Information Security Awareness video and UMMC Acceptable Use Policy .
* Please review the Compliance Training .
Once you have reviewed the training material and policy, you will need to complete the acknowledgment statements below.
* I acknowledge that I have viewed the Information Security Awareness video
and have read, understand, and agree to abide by the security policies in the UMMC Acceptable Use Policy.
* I acknowledge that I have read, understood, and agree to abide by the Compliance Training provided.
*
I acknowledge that for the duration of my engagement with the University of Mississippi Medical Center (UMMC) that I have an affirmative
obligation to immediately disclose any changes to my criminal history record including charges resulting from arrests, criminal convictions
of both misdemeanor and felony crimes, and addition to a sex offender registry after my date of background clearance. I attest that
I have submitted any changes to my criminal history record to UMMC Human Resources using the
Change of Criminal History Record
Disclosure Form since the date of my last background clearance.
By submitting this form, I acknowledge that all information presented is true and accurate to the best of my knowledge. I understand
that I am not authorized to engage with the institution until notified by a UMMC sponsor that the request has been approved and that all UMMC onboarding
requirements and procedures are complete.