Request for Employee Designee Affiliate


Affiliates are individuals who receive University services and who are not students, employees, or non-paid appointees.

The following form is to be completed by a Regular employee (or Contingent II employee if included in their contract) of the University of Maryland to designate one qualified person in addition to himself/herself to be eligible to receive campus-based privileges. To receive a form in Adobe Sign, please contact Natalie Torres at ntorres@umd.edu. The employee must then complete the form (all fields are required), attest to the statement qualifying the individual who will receive services, and sign. Upon UHR entering the data in PHR Affiliates system, the Employee Designee Affiliate will be eligible for those campus-based privileges as designated.