Non-Company

Workers Information Form

Account Authorization / Verification
This form must be completed by supervisor of any non-company workers, local hires or seconded workers. Once completed, both
supervisor and worker must sign this form. Only seconded workers need to complete page 2.

Basic Worker Information (this information must be completed for all non-company workers)
Full Name: Leanna Cinquanta Country Citizenship: USA
Preferred Name: Leanna Date of Birth: Dec 27, 1970
Physical Address: 12650 W 64th Ave. #245
Telephone Number: 888-887-6066 Cell Number: 970-985-8744
Email Address: leanna@tellasia.org

Non-Company Worker category (please check only one) Local Hire Seconded

Term
(Please enter end date for term of worker, if nothing entered account will require verification six (6) months from request date. Maximum term is one year for non-
worker account authorizations.)
Request Date - Term End Date -

Supervisor Information (this information must be completed for all non-company workers)
Name: Company email address:

Account Authorization Requested / Verified

(Please check below the account authorizations being requested / verified.)

MSNPath email Rationale

(non-company workers do not receive access to the GAL. Exceptions must be processed through AOD, OIS)

WebEx Rationale
Application 1 Rationale
Application 2 Rationale
Application 3 Rationale

Non-Company Worker Certification

By signing below, you acknowledge and agree that 1.) you receive these accounts, access and authorizations only for and in your
role as a non-company worker; 2.) provisioning such accounts, access and authorizations does not in any way constitute an
employment relationship with the company; 3.) you will follow all policies regarding use of any company accounts, access or
authorizations you may be provisioned with.

Leanna Cinquanta Leanna Cinquanta July 11 2017

Non-company worker name Signature Date

Supervisor Certification
By signing below, you as the supervisor request / verify that the above listed account, access and authorization is needed for the
above named non-company worker to perform their work. You also acknowledge that you are responsible to immediately notify the
Personnel Service Center of any change to worker status.

Supervisor name Signature Dept./Team Date

Non-Company Workers Information Form
Account Authorization / Verification
Only seconded workers need to complete this section.

Head of household
Full Name as on Passport: Passport No:
Passport Expiration Date:
Spouse (if married)
Full Name as on Passport: Country of Citizenship:
Preferred Name: Passport No:
Date of Birth: Passport Expiration Date:
Physical Address:
Telephone Number(s): Cell Number:
Email Address:

Sending Organization and/or Home Church

Sending Church / Organization:
Address:
Contact Person:
Phone number(s):
Email address:
Is the church a Southern Baptist Church?

Children with you on the field? (If so, please give the following for information for each child. Add additional children, as needed.)
Child #1
Full Name on Passport: Country of Citizenship:
Preferred Name: Passport No:
Date of Birth: Passport Expiration Date:
Child #2
Full Name on Passport: Country of Citizenship:
Preferred Name: Passport No:
Date of Birth: Passport Expiration Date:
Child #3
Full Name on Passport: Country of Citizenship:
Preferred Name: Passport No:
Date of Birth: Passport Expiration Date:

Emergency Contact Information In priority order, list the people that we should contact in the event of an emergency.
1. Name: Relationship:
Phone: Email:

2. Name: Relationship:
Phone: Email:

3. Name: Relationship:
Phone: Email:

4. Name: Relationship:
Phone: Email:

5. Name: Relationship:
Phone: Email: