SAVANNAH STATE UNIVERSITY
Payroll Form: Student Fellowship Request
Print
62210
Request Number: __________________
Recipient Information
Reset
,
Recipient Name: ____________________________________________________________________________________
Last Name
First Name
Employee ID Number**: _____________________________
Last four of SSN: __________________
**If this is your first time working for the University, please leave this field blank. An ADP Employee ID Number will be assigned to you by Human
Resources upon the processing of this form. If you have been assigned an ADP Employee ID Number, you must complete this field.
Address: __________________________________________________________________________________________
City: _______________________________
State:
Phone: _______________________________ Type:
GA
Zip Code: ____________
Cell
Home
Work
Signature: _______________________________ Date: _______________
Supervisor Information
Name: ____________________________________________________________________________________________
Department: ____________________________________________________
Extention: ________________________
Signature: _______________________________ Date: _______________
Fellowship Information
For up to 12 months worth of Fellowship payments
(For over 12 payments, please submit an attachment)
Start Date: ____________________________________________________
End Date: ____________________________________
Dept of Employment: ____________________________________________________
Weekly Hours: _________________
Monthly Rate: _________________
Project #: _________________________
Total Hours: _________________
Total Award: _________________
Fellowship Payment Schedule
Requested Pay Date
Requested Pay Date
Amount
1.
2.
3.
4.
5.
6.
Amount
7.
8.
9.
10.
11.
12.
Total Number of Payments
0
Total Amount of Payments
Budget Unit Head: ____________________________________________________________
$ 0.00
Date: ______________
For Business & Financial Affairs and Human Resources Use ONLY
Budget Officer/Grants Office: ___________________________________________________
Date: ______________
ADP Number: ___________________________________________________________________________________
Human Resources Officer: ______________________________________________________ Date: ______________