Common use of CERTIFICATION AND SIGNATURE Clause in Contracts

CERTIFICATION AND SIGNATURE. This is to certify that the person named above meets all the eligibility criteria for the Household Member. I understand that I will be responsible for paying any costs for enrollment in the plan and any taxes associated with enrolling a Household Member.* I also understand that any information falsified on this document may result in discipline up to and including termination from employment. Faculty Member Name: IN: (First, Middle Initial, Last) Faculty Member Signature: Date: *The Employer cost of providing health benefits for Household Members is considered ordinary income and is, therefore, subject to taxes, including social security, Medicare, federal and state taxes. AFFIDAVIT OF TERMINATION OF BENEFITS FOR HOUSEHOLD MEMBER I, , affirm the health benefit coverage for my Household Member (Print name of faculty/staff member) listed on the Enrollment Form dated , should be terminated as of . Termination of coverage for my Household Member is due to (check one): Household Member no longer meets the required eligibility criteria Death of Household Member Coverage no longer needed by the Household Member (obtained other coverage) I HEREBY AGREE TO MAIL A COPY OF THIS AFFIDAVIT TO MY SURVIVING FORMER HOUSEHOLD MEMBER. Faculty/Staff Member Signature Date Appendix D NAME: DATE: DEPARTMENT: NORTHERN MICHIGAN UNIVERSITY FACULTY EVALUATION REPORT Evaluation Period (1-2 Calendar Years) This is a confidential evaluation report on a member of the Northern Michigan University faculty. Its content will not be divulged to persons not authorized to help prepare or read this report. Access to the personnel file of any member of the faculty shall be restricted to the faculty member, his/her department head, departmental evaluation committee, xxxx, College Advisory Council, FRC, PVPAA, President of the University, the Board of Trustees and its counsel, and other persons who have a legal reason to know the contents of the evaluation. Evaluation Period: Tenured Full Professors will be evaluated every five years; other faculty will be evaluated annually. A Tenured Full Professor, the departmental evaluation committee, or the department head may request an annual evaluation. Faculty evaluation is described in the NMU/AAUP Agreement in Sections 5.4 through 5.6 and Article VI. Style: Writing in the evaluations is to be a narrative that is to the point and supported with evidence. NAME POSITION DATE Committee Members: Others: NORTHERN MICHIGAN UNIVERSITY FACULTY EVALUATION REPORT Evaluation Period (1-2 Calendar Years) Appendix D Name: Department: Part I

CERTIFICATION AND SIGNATURE. This is to certify that the person named above meets all the eligibility criteria for the Household Member. I understand that I will be responsible for paying any costs for enrollment in the plan and any taxes associated with enrolling a Household Member.* I also understand that any information falsified on this document may result in discipline up to and including termination from employment. Faculty Member Name: IN: (First, Middle Initial, Last) Faculty Member Signature: Date: *The Employer cost of providing health benefits for Household Members is considered ordinary income and is, therefore, subject to taxes, including social security, Medicare, federal and state taxes. AFFIDAVIT OF TERMINATION OF BENEFITS FOR HOUSEHOLD MEMBER I, , affirm the health benefit coverage for my Household Member listed on the Enrollment (Print name of faculty/staff member) listed on the Enrollment Form dated , should be terminated as of . Termination of coverage for my Household Member is due to (check one): Household Member no longer meets the required eligibility criteria Death of Household Member Coverage no longer needed by the Household Member (obtained other coverage) I HEREBY AGREE TO MAIL A COPY OF THIS AFFIDAVIT TO MY SURVIVING FORMER HOUSEHOLD MEMBER. Faculty/Staff Member Signature Date Appendix D NAME: DATE: DEPARTMENT: Appendix D NORTHERN MICHIGAN UNIVERSITY FACULTY EVALUATION REPORT Evaluation Period (1-2 Calendar Years) This is a confidential evaluation report on a member of the Northern Michigan University faculty. Its content will not be divulged to persons not authorized to help prepare or read this report. Access to the personnel file of any member of the faculty shall be restricted to the faculty member, his/her department head, departmental evaluation committee, xxxx, College Advisory Council, FRC, PVPAA, President of the University, the Board of Trustees and its counsel, and other persons who have a legal reason to know the contents of the evaluation. Evaluation Period: Tenured Full Professors will be evaluated every five years; other faculty will be evaluated annually. A Tenured Full Professor, the departmental evaluation committee, or the department head may request an annual evaluation. Faculty evaluation is described in the NMU/AAUP Agreement in Sections 5.4 through 5.6 and Article VI. Style: Writing in the evaluations is to be a narrative that is to the point and supported with evidence. NAME POSITION DATE Committee Members: Others: NORTHERN MICHIGAN UNIVERSITY FACULTY EVALUATION REPORT Evaluation Period (1-2 Calendar Years) Appendix D Name: Department: Part I

CERTIFICATION AND SIGNATURE. This is to certify that the person named above meets all the eligibility criteria for the Household Member. I understand that I will be responsible for paying any costs for enrollment in the plan and any taxes associated with enrolling a Household Member.* I also understand that any information falsified on this document may result in discipline up to and including termination from employment. Faculty Member Name: IN: (First, Middle Initial, Last) Faculty Member Signature: Date: *The Employer cost of providing health benefits for Household Members is considered ordinary income and is, therefore, subject to taxes, including social security, Medicare, federal and state taxes. AFFIDAVIT OF TERMINATION OF BENEFITS FOR HOUSEHOLD MEMBER I, , affirm the health benefit coverage for my Household Member (Print name of faculty/staff member) listed on the Enrollment Form dated , should be terminated as of . Termination of coverage for my Household Member is due to (check one): Household Member no longer meets the required eligibility criteria Death of Household Member Coverage no longer needed by the Household Member (obtained other coverage) I HEREBY AGREE TO MAIL A COPY OF THIS AFFIDAVIT TO MY SURVIVING FORMER HOUSEHOLD MEMBER. Faculty/Staff Member Signature Date Appendix D NAME: DATE: DEPARTMENT: NORTHERN MICHIGAN UNIVERSITY FACULTY EVALUATION REPORT Evaluation Period (1-2 Calendar Years) This is a confidential evaluation report on a member of the Northern Michigan University faculty. Its content will not be divulged to persons not authorized to help prepare or read this report. Access to the personnel file of any member of the faculty shall be restricted to the faculty member, his/her department head, departmental evaluation committee, xxxx, College Advisory Council, FRCFaculty Review Committee, PVPAAXxxxxxx and Vice President for Academic Affairs, President of the University, the Board of Trustees and its counsel, and other persons who have a legal reason to know the contents of the evaluation. Evaluation Period: Tenured Full Professors will be evaluated every five years; other faculty will be evaluated annually. A Tenured Full Professor, the departmental evaluation committee, or the department head may request an annual evaluation. Faculty evaluation is described in the NMU/AAUP Agreement in Article V, Section 5.4; Article V, Sections 5.4 5.2, and 5.5 through 5.6 5.7; and Article Articles VI. Style: Writing , VIII, IX also contain information useful in the evaluations is to be a narrative that is to the point and supported with evidence. NAME POSITION DATE Committee Members: Others: NORTHERN MICHIGAN UNIVERSITY FACULTY EVALUATION REPORT Evaluation Period (1-2 Calendar Years) Appendix D Name: Department: Part Ipreparing evaluations.

CERTIFICATION AND SIGNATURE. This is to certify that the person named above meets all the eligibility criteria for the Household Member. I understand that I will be responsible for paying any costs for enrollment in the plan and any taxes associated with enrolling a Household Member.* I also understand that any information falsified on this document may result in discipline up to and including termination from employment. Faculty Member Name: IN: (First, Middle Initial, Last) Faculty Member Signature: Date: *The Employer cost of providing health benefits for Household Members is considered ordinary income and is, therefore, subject to taxes, including social security, Medicare, federal and state taxes. AFFIDAVIT OF TERMINATION OF BENEFITS FOR HOUSEHOLD MEMBER I, , affirm the health benefit coverage for my Household Member (Print name of faculty/staff member) listed on the Enrollment Form dated , should be terminated as of . Termination of coverage for my Household Member is due to (check one): Household Member no longer meets the required eligibility criteria Death of Household Member Coverage no longer needed by the Household Member (obtained other coverage) I HEREBY AGREE TO MAIL A COPY OF THIS AFFIDAVIT TO MY SURVIVING FORMER HOUSEHOLD MEMBER. Faculty/Staff Member Signature Date Appendix D NAME: DATE: DEPARTMENT: NORTHERN MICHIGAN UNIVERSITY FACULTY EVALUATION REPORT Evaluation Period (1-2 Calendar Years) This is a confidential evaluation report on a member of the Northern Michigan University faculty. Its content will not be divulged to persons not authorized to help prepare or read this report. Access to the personnel file of any member of the faculty shall be restricted to the faculty member, his/her department head, departmental evaluation committee, xxxx, College Advisory Council, FRC, PVPAA, President of the University, the Board of Trustees and its counsel, and other persons who have a legal reason to know the contents of the evaluation. Evaluation Period: Tenured Full Professors will be evaluated every five years; other faculty will be evaluated annually. A Tenured Full Professor, the departmental evaluation committee, or the department head may request an annual evaluation. Faculty evaluation is described in the NMU/AAUP Agreement in Sections 5.4 through 5.6 and Article VI. Style: Writing in the evaluations is to be a narrative that is to the point and supported with evidence. NAME POSITION DATE Committee Members: Others: NORTHERN MICHIGAN UNIVERSITY FACULTY EVALUATION REPORT Evaluation Period (1-2 Calendar Years) Appendix D Name: Department: Appendix D Part I

CERTIFICATION AND SIGNATURE. This is to certify that the person named above meets all the eligibility criteria for the Household Member. I understand that I will be responsible for paying any costs for enrollment in the plan and any taxes associated with enrolling a Household Member.* I also understand that any information falsified on this document may result in discipline up to and including termination from employment. Faculty Member Name: IN: (First, Middle Initial, Last) Faculty Member Signature: Date: *The Employer cost of providing health benefits for Household Members is considered ordinary income and is, therefore, subject to taxes, including social security, Medicare, federal and state taxes. AFFIDAVIT OF TERMINATION OF BENEFITS FOR HOUSEHOLD MEMBER I, , affirm the health benefit coverage for my Household Member (Print name of faculty/staff member) listed on the Enrollment Form dated , should be terminated as of . Termination of coverage for my Household Member is due to (check one): Household Member no longer meets the required eligibility criteria Death of Household Member Coverage no longer needed by the Household Member (obtained other coverage) I HEREBY AGREE TO MAIL A COPY OF THIS AFFIDAVIT TO MY SURVIVING FORMER HOUSEHOLD MEMBER. Faculty/Staff Member Signature Date Appendix D NAME: DATE: DEPARTMENT: NORTHERN MICHIGAN UNIVERSITY FACULTY EVALUATION REPORT Evaluation Period (1-2 Calendar Years) This is a confidential evaluation report on a member of the Northern Michigan University faculty. Its content will not be divulged to persons not authorized to help prepare or read this report. Access to the personnel file of any member of the faculty shall be restricted to the faculty member, his/her department head, departmental evaluation committee, xxxx, College Advisory Council, FRC, PVPAA, President of the University, the Board of Trustees and its counsel, and other persons who have a legal reason to know the contents of the evaluation. Evaluation Period: Tenured Full Professors will be evaluated every five years; other faculty will be evaluated annually. A Tenured Full Professor, the departmental evaluation committee, or the department head may request an annual evaluation. Faculty evaluation is described in the NMU/AAUP Agreement in Sections 5.4 5.2, 5.4, and 5.5 through 5.6 5.7; and Article Articles VI. Style: Writing , VIII, IX also contain information useful in the evaluations is to be a narrative that is to the point and supported with evidence. NAME POSITION DATE Committee Members: Others: NORTHERN MICHIGAN UNIVERSITY FACULTY EVALUATION REPORT Evaluation Period (1-2 Calendar Years) Appendix D Name: Department: Part Ipreparing evaluations.

CERTIFICATION AND SIGNATURE. This is to certify that the person named above meets all the eligibility criteria for the Household Member. I understand that I will be responsible for paying any costs for enrollment in the plan and any taxes associated with enrolling a Household Member.* I also understand that any information falsified on this document may result in discipline up to and including termination from employment. Faculty Member Name: IN: (First, Middle Initial, Last) Faculty Member Signature: Date: *The Employer cost of providing health benefits for Household Members is considered ordinary income and is, therefore, subject to taxes, including social security, Medicare, federal and state taxes. AFFIDAVIT OF TERMINATION OF BENEFITS FOR HOUSEHOLD MEMBER I, , affirm the health benefit coverage for my Household Member (Print name of faculty/staff member) listed on the Enrollment Form dated , should be terminated as of . Termination of coverage for my Household Member is due to (check one): Household Member no longer meets the required eligibility criteria Death of Household Member Coverage no longer needed by the Household Member (obtained other coverage) I HEREBY AGREE TO MAIL A COPY OF THIS AFFIDAVIT TO MY SURVIVING FORMER HOUSEHOLD MEMBER. Faculty/Staff Member Signature Date Appendix D NAME: DATE: DEPARTMENT: MEMORANDUM OF UNDERSTANDING #2 BETWEEN NORTHERN MICHIGAN UNIVERSITY FACULTY EVALUATION REPORT Evaluation Period (1-2 Calendar Years) AND AMERICAN ASSOCIATION OF UNIVERSITY PROFESSORS- NORTHERN MICHIGAN UNIVERSITY CHAPTER 2009 This is a confidential evaluation report on a member Memorandum of the Understanding executed between Northern Michigan University faculty. Its content will not be divulged (hereinafter referred to persons not authorized as the University), and the American Association of University Professors-Northern Michigan University Chapter (hereinafter referred to help prepare or read this report. Access to as the personnel file of any member of Association), the recognized bargaining unit agent for certain faculty shall be restricted to the faculty member, his/her department head, departmental evaluation committee, xxxx, College Advisory Council, FRC, PVPAA, President of employed by the University, whereas the Board parties agree as follows: It is the intent of Trustees Northern Michigan University to remedy inappropriate salary inversions resulting from promotions. The University and the Association agree to institute a Faculty Salary Inversion Review Committee, composed of three (3) members appointed by the association and three (3) members appointed by the Xxxxxxx and Vice President for Academic Affairs to monitor salary inversions that may arise from the promotion structure in the 2009-2012 Agreement and to recommend adjustments to the Xxxxxxx and Vice President for Academic Affairs. The Review Committee shall meet and make its counselrecommendations to the Xxxxxxx and Vice President for Academic Affairs as soon after salary increases have been implemented as practicable. A potential salary inversion arises when the salary of a newly promoted faculty member is greater than colleagues at the same rank and in the same discipline. Not every inversion needs to be adjusted, however. If a faculty member with extraordinary attainments and other persons who have accompanying above average salary is promoted and has a legal post-promotion salary larger than others at the new rank, then there is no prima facie reason to know adjust the contents of the evaluation. Evaluation Period: Tenured Full Professors will be evaluated every five years; other faculty will be evaluated annually. A Tenured Full Professor, the departmental evaluation committee, or the department head may request an annual evaluation. Faculty evaluation is described in the NMU/AAUP Agreement in Sections 5.4 through 5.6 and Article VI. Style: Writing in the evaluations is to be a narrative that is to the point and supported with evidence. NAME POSITION DATE Committee Members: Others: NORTHERN MICHIGAN UNIVERSITY FACULTY EVALUATION REPORT Evaluation Period (1-2 Calendar Years) Appendix D Name: Department: Part Iinverted salaries.