initiator:hr_department@lockhaven.edu;wfState:distributed;wfType:email;workflowId:069442c5f51ebf408a62646e19aaa66d

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This form has been developed by Pennsylvania’s State System of Higher Education, pursuant to Pennsylvania’s Child Protective Services Law, 23 Pa.C.S. § 6301 et seq. February 5, 2015

Pennsylvania’s State System of Higher Education Background Clearance Certification

for Provisional Employment or Volunteering (Under the Child Protective Services Law)

Please read this entire form carefully before completing it. This form is to be used by prospective volunteers who reside in another state or country and employees to meet the written certification requirement to be considered as a provisional hire or volunteer assignment. This form does not apply to volunteers who reside in Pennsylvania. In certain limited circumstances, current employees/volunteers may need to complete this form.

Section 1. Personal Information

Full Legal Name: __________________________________________________ Date of Birth: _______________

Any former names or aliases by which you have been identified: _____________________________________________

Section 2. Instructions

If you have any question about whether to report an offense, you should report it. Failure to report may result in disqualification for employment.

List of Reportable Offenses

A Reportable Offense enumerated under Pennsylvania’s Child Protective Services Law, 23 Pa.C.S. § 6344(c), consists of one or more of the following:

1. Provisions of Title 18 of the Pennsylvania Consolidated Statutes (relating to crimes and offenses) or an equivalentcrime under the laws or former laws of the United States or one of its territories or possessions, another state, theDistrict of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of theCommonwealth of Pennsylvania:

Chapter 25 relating to criminal homicide Section 2702 relating to aggravated assault Section 2709.1 relating to stalking Section 2901 relating to kidnapping Section 2902 relating to unlawful restraint Section 3121 relating to rape Section 3122.1 relating to statutory sexual assault Section 3123 relating to involuntary deviate sexual

intercourse Section 3124.1 relating to sexual assault Section 3125 relating to aggravated indecent assault Section 3126 relating to indecent assault

Section 3127 relating to indecent exposure Section 4302 relating to incest Section 4303 relating to concealing death of a child Section 4304 relating to endangering welfare of

children Section 4305 relating to dealing in infant children A felony offense under Section 5902(b) relating to

prostitution and related offenses Section 5903(c) or (d) relating to obscene and other

sexual materials and performances Section 6301 relating to corruption of minors Section 6312 relating to sexual abuse of children

2. An offense designated as a felony under the act of April 14, 1972 (P.L. 233, No. 64), known as “The ControlledSubstance, Drug, Device and Cosmetic Act,” committed within the preceding five-year period.

3. A founded report of child abuse within the preceding five-year period in the statewide database maintained by theDepartment of Human Services.

mm/dd/yyyy

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This form has been developed by Pennsylvania’s State System of Higher Education, pursuant to Pennsylvania’s Child Protective Services Law, 23 Pa.C.S. § 6301 et seq. February 5, 2015

Section 3. No Conviction

By checking this box, I certify that I have not been convicted of any Reportable Offense or an offense similar in nature to a Reportable Offense under the laws or former laws of the United States or one of its territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of the Commonwealth of Pennsylvania. (See Section 2 for a list of Reportable Offenses.)

Section 4. Application for Background Checks

I certify that I have applied for the following required background clearance checks:

A report of criminal history record from the Pennsylvania State Police (PSP) or statement from the PSP that no criminal record exists.

Certification from the Pennsylvania Department of Human Services as to whether I am named in the statewide database as a perpetrator in a pending child abuse investigation or in a founded report or indicated report of child abuse.

A report of federal criminal history record information. I understand that I must submit a full set of fingerprints to the PSP to obtain this report.

I further certify that I have provided copies of the completed request forms for these background clearance checks to Pennsylvania’s State System of Higher Education. (Appropriate forms may be attached to this Certification Form.)

Section 5. Certification

By signing this form, I swear and affirm under penalty of law that the statements made in this form are true, accurate, correct, and complete. I understand that false statements herein, including, without limitation, any failure to accurately report any arrest or conviction for a Reportable Offense, shall subject me to criminal prosecution under 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities.

I understand that after successful completion of the criminal background clearance process, I have a continuing obligation to notify the Human Resources Department within seventy-two (72) hours after an arrest or conviction for an offense defined in the “Reportable Offense” list. If I am unsure about the applicability of my arrest or conviction as a Reportable Offense, it is my responsibility to notify the Human Resources Department for further review. I understand that failure to disclose any arrest or conviction of a “Reportable Offense” shall be considered as non-compliance, subject to disciplinary action, up to and including termination, and/or criminal prosecution, as applicable.

_____________________________________________________ _____________________________________ Signature Date mm/dd/yyyy

LOCK HAVEN UNIVERSITY OF PA Student Application for New Employment or Fund Center Change

*Student may not begin work until employment paperwork is completeIt is the policy of the PASSHE that you cannot work until you have a social security number

If your address changes at any time, please notify Student Payroll

Name

PERNR# - Completed by Payroll

Social Security Number

Local or Cell Telephone Number Date of Birth

PU.S. Citizen

lease mark the appropriate box.

Resident or Nonresident Alien (Every calendar year you must complete Statement of Citizenship in the International Office. You will not be put on the payroll until all paperwork is completed.)

Gender: Male Female

Check here if you are a veteran

Currently enrolled in classes at Lock Haven University

I declare that this statement, to the best of my knowledge, is true and correct. Falsifying hours worked will result in IMMEDIATE TERMINATION of Student Employment Student Signature Date

LHUP E-mail address

NOTE TO SUPERVISORS: Students may work no more than 20 hours per week during the semesters. Prior approval must be obtained, in writing, from Department of Student Affairs to work more than 20 hours. Students may work 37.5 hours per week, a maximum of 7.5 in a day, during summer and scheduled breaks provided there are sufficient monies in your department fund center.

Completed paperwork is to be forwarded to Student Payroll Office, EC J207. Students may not begin working until the student and supervisor receive an email from payroll saying they are cleared to work.

1. ______________________________ _______________ Department Date

__ __ __ __ __ __ __ __ __ __.__ __ __ __ __ 10 digit Fund Center (Grant WBS)

2. _____________________________Supervisor - Printed Name Supervisor - Signature

________________________________

Hire Date

mm/dd/yyyy

mm/dd/yyyy

LOCAL EARNED INCOME TAXRESIDENCY CERTIFICATION FORM

DCED-CLGS-06 (1-11) COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF COMMUNITY & ECONOMIC DEVELOPMENT

GOVERNOR’S CENTER FOR LOCAL GOVERMENT SERVICES

EMPLOYEE INFORMATION - PERMANENT RESIDENCE LOCATION

TO EMPLOYERS/TAXPAYERS:

This form is to be used by employers and/or taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes.

This form must be utilized by employers when a new employee is hired or when a current employee notifies employer of a name and/or address change.

NAME (Last, FIrst, Middle Initial)

FIRST LINE OF ADDRESS (If PO Box, please include actual street address)

SECOND LINE OF ADDRESS

CITY STATE ZIP CODE DAYTIME PHONE NUMBER

CERTIFICATION

SIGNATURE OF EMPLOYEE DATE

PHONE NUMBER EMAIL ADDRESS

MUNICIPALITY (City, Borough, Township) Write Municipality name and Circle Municipality type

COUNTY PSD CODE Payroll Use Only TOTAL RESIDENT EIT RATE

EMPLOYER INFORMATION - EMPLOYMENT LOCATION

EMPLOYER NAME (Use Federal ID Name) EMPLOYER FEIN

FIRST LINE OF ADDRESS (IIf PO Box, please include actual street address)

SECOND LINE OF ADDRESS

CITY STATE ZIP CODE PHONE NUMBER

MUNICIPALITY (City, Borough, Township)

COUNTY PSD CODE MUNICIPAL NON-RESIDENT EIT RATE

For information on obtaining the appropriate MUNICIPALITY (City, Borough, Township), PSD CODES and EIT (Earned Income Tax) RATES,

please refer to the Pennsylvania Department of Community & Economic Development website:

www.newPA.com

Select Get Local Gov Support, >Municipal Statistics

Form W-4 (2019)Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. You may claim exemption from withholding for 2019 if both of the following apply.• For 2018 you had a right to a refund of all federal income tax withheld because you had no tax liability, and• For 2019 you expect a refund of all federal income tax withheld because you expect to have no tax liability.If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2019 expires February 17, 2020. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General InstructionsIf you aren’t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2019 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider

using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income not subject to withholding outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2019. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married filing jointly and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. Nonwage income. If you have a large amount of nonwage income not subject to withholding, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Additional Income Worksheet on page 3 or the calculator at www.irs.gov/W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Specific InstructionsPersonal Allowances WorksheetComplete this worksheet on page 3 first to determine the number of withholding allowances to claim.Line C. Head of household please note: Generally, you may claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.

Line E. Child tax credit. When you file your tax return, you may be eligible to claim a child tax credit for each of your eligible children. To qualify, the child must be under age 17 as of December 31, must be your dependent who lives with you for more than half the year, and must have a valid social security number. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.Line F. Credit for other dependents. When you file your tax return, you may be eligible to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as a qualifying child who doesn’t meet the age or social security number requirement for the child tax credit, or a qualifying relative. To learn more about this credit, see Pub. 972. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total

Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate▶ Whether you’re entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20191 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note: If married filing separately, check “Married, but withhold at higher Single rate.”

4 If your last name differs from that shown on your social security card,

check here. You must call 800-772-1213 for a replacement card. ▶

5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . . 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2019, and I certify that I meet both of the following conditions for exemption.

• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7

Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)

9 First date of employment

10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2019)

LOCK HAVEN UNIVERSITY OF PENNSYLVANIA 

ETHNICITY/RACE INFORMATION 

A racial identification code is an integral part of the personnel records of every employee at Lock Haven University.  All information is confidential. 

Please provide accurate information. 

1. WHAT IS YOUR ETHNICITY? (Select One Option)

Hispanic or Latino 

Persons of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race. 

Not Hispanic or Latino 

2. WHAT IS YOUR RACE? (Select one or more)

American Indian or Alaska Native 

Persons having origins in any of the original peoples of North and South America (including Central America). 

Asian 

Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. 

Black or African American 

Persons having origins in any of the black racial groups of Africa. 

Native Hawaiian or Pacific Islander 

Persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific islands. 

White/Caucasian 

Persons having origins in any of the original peoples of Europe, the Middle East, or North Africa. 

Signature______________________________________ Date_______________ mm/dd/yyyy

Undergraduate Student Employment Practices

Lock Haven University of PA

In accordance with the Board of Governors Policy, 1983-10, Lock Haven University of PA [hereafter the

University or LHUP] has established undergraduate student employment practices for Campus

Employment and Federal Work Study [FWS] employment. Students receiving financial aid who are

interested in Federal Work Study may be granted those funds through the Student Financial Services [SFS]

Office located in Ulmer Hall. Students may identify both Campus Employment and FWS employment

opportunities through LHUP website.

General Guidelines

Students earn minimum wage and are permitted to work up to 20 hours per week during the

academic year.

Students may work up to 20 hours during the academic year and 37.5 hours per week during the

summer and scheduled breaks.

It is recommended that first year students be limited to no more than 15 hours per week during the

academic year.

Students cannot be assigned to work directly for any family members.

Students may not work for more than two fund centers, and the total combined hours worked

cannot exceed 20 hours during the academic year and 37.5 hours during the summer.

Special permission to work more than 20 hours per week may be requested through the Vice

President of Student Affairs, Ulmer Hall.

No student may work more than 7.5 hours in a single day.

Students must be enrolled for at least six credits each semester as a regular LHU student.

Students seeking employment for the summer must be enrolled either for a summer session or for

the next fall session.

Students returning to work in the same office need not complete the employment application

process again unless there is a change in fund center.

Students may identify employment opportunities through the following website:

http://www.lockhaven.edu/career/

Any student enrolled at the University may be employed through Campus Employment.

Campus Employment is funded through established fund centers and is subject to budget

restrictions. A fund center is assigned a specific amount of student employment funding at the

beginning of the fall semester which can be used to fund as many students as funding permits.

The fund center supervisor is responsible for monitoring the number of hours students are

assigned. Exceptions may be granted by the Vice President of Student Affairs for students who

wish to exceed the maximum number of hours per week.

Student employment forms for LHUP students are available on the LHUP web site.

Students must complete the required employment forms, which should then be given to their

department supervisor/timekeeper for review and signature. Supervisors/timekeepers must review

all forms for completeness. Supervisors/timekeepers shall forward all completed forms to the

Human Resources Office.

No student may begin working until they receive an email from Human Resources indicating they

are cleared to work, the supervisor will be copied. The cleared to work email will be sent after all

forms are completed, signed, reviewed and all registrations for clearances have been provided.

I, ________________________________________ (print name), affirm that I have read and

understand the above guidelines and agree to abide by them.

__________________________________________ __________________

Signature of LHUP Student Employee Date mm/dd/yyyy

State System of Higher Education The System Works for Pennsylvania

Tired of going to the bank or waiting in line to cash your check? Introduce yourself to Direct Deposit.

How Direct Deposit works: The State System of Higher Education notifies your Financial Institution electronically of the funds to be deposited on your behalf. Your Financial Institution records this transaction into an account of your choice, creating immediate access on the day of deposit. You receive an earnings statement documenting this payment.

It’s convenient - saves you a trip to the bank.It’s faster - most banks post the funds to your account at the beginning

of the day’s business on payday allowing immediate access. It’s safer - Direct Deposit eliminates the worry of a lost or stolen paycheck. It’s confidential - funds are automatically processed and you can instruct the

bank to apply them to your savings or checking account.

Sign up today by completing the form below and contacting your Human Resource Office. ---------------------------------------------------------------------------------------------------------------------

Direct Deposit Authorization

Name___________________________ SAP PERNR # Completed by Payroll ________________

I hereby authorize the State System of Higher Education to (check one) ___ Start ___ Change ___ Stop total bi-weekly payroll deduction to the Financial Institution shown below. You may designate any bank, savings and loan association, or credit union in the U.S. that (1) is a member of the Federal Reserve System and (2) accepts electronic funds transfer. Payroll will notify you if the institution you choose does not qualify.

Financial Institution’s Name___________________________ Transit Routing Number______________________________ Account Number____________________________________ Type of Account____________________________________ (Checking or Savings)

Effective with pay date of_____________________________

I have an established account at the Financial Institution indicated above, and authorize the State System of Higher Education to initiate credit entries and to initiate debit entries and adjustments for any credit entries in error to my (our) account(s) indicated above. I have provided a copy of a voided check (see attached) solely for the purpose of verifying my account number and the Financial Institution’s routing number. My authorization will remain in effect until revoked by me in writing or I terminate my employment with the State System of Higher Education.

Date_______________________ Signature________________________________________

Co-Signature (If Joint Account)________________________________________

I:\Payroll\BEH\Direct Deposit Authorization

mm/dd/yyyy

mm/dd/yyyy

LOCAL SERVICES TAX – EXEMPTION CERTIFICATE 2018

Tax Year

APPLICATION FOR EXEMPTION FROM LOCAL SERVICES TAX

A copy of this application for exemption from the Local Services Tax (LST), and all necessary supporting documents, must be completed and presented to your employer AND to the political subdivision levying the Local Services Tax for the municipality or school district in which you are primarily employed.

This application for exemption from the Local Services Tax must be signed and dated.

No exemption will be approved until proper documentation has been received.

Name: Address:

City/State:

Soc Sec #: Phone #:

Zip:

REASON FOR EXEMPTION

1._______ MULTIPLE EMPLOYERS: Attach a copy of a current pay statement from your principal

employer that shows the name of the employer, the length of the payroll period and the amount of Local Services Tax withheld. List all employers on the reverse side of this form. You must notify

your other employers of a change in principal place of employment within two weeks of the

change.

2. ______ EXPECTED TOTAL EARNED INCOME AND NET PROFITS FROM ALL SOURCES

WITHIN City of Lock Haven (municipality or school

district) WILL BE LESS THAN $ 12,000.00 : Attach copies of your last pay statements or

your W-2 for the year prior.

If you are self-employed, please attach a copy of your PA Schedule C, F, or RK-1 for the prior

year.

3._______ ACTIVE DUTY MILITARY EXEMPTION: Please attach a copy of your orders directing you to

active duty status. Annual training is not eligible for exemption. You are required to advise the

tax office when you are discharged from active duty status.

4._______ MILITARY DISABILITY EXEMPTION: Please attach copy of your discharge orders and a

statement from the United States Veterans Administrator documenting your disability. Only 100% permanent disabilities are recognized for this exemption.

EMPLOYER: Once you receive this Exemption Certificate, you shall not withhold the Local Services Tax for the

portion of the calendar year for which this certificate applies, unless you are otherwise notified or instructed by the

tax collector to withhold the tax.

Tax Office: City of Lock Haven Address: 20 E. Church St.

City/State: Lock Haven, PA

Phone #: 570-893-5621

Zip: 17745

IMPORTANT NOTE TO EMPLOYERS 1. The municipality is required by law to exempt from the LST employees whose earned income from all sources (employers

and self-employment) in their municipality is less than $12,000 when the combined rate exceeds $10.00.

2. The school district for the municipality in which your worksite(s) is located may or may not levy an LST. If it does, the

income exemption provided may differ from the municipality and can be anywhere from $0 to $11,999.

3. Contact the tax office where your business worksites are located to obtain this information.

LST Exemption 10-07

Employment Information: List all places of employment for the applicable tax year. Please list your

PRIMARY EMPLOYER under #1 below and your secondary employers under the other columns. If self

employed, write SELF under Employer Name column.

1. PRIMARY EMPLOYER 2. 3.

Employer Name Lock Haven University

Address 301 W. Church St.

Address 2

City, State Zip Lock Haven, PA

Municipality Lock Haven

Phone 570-484-2230

Start Date 1/1/18

End Date 12/31/18

Status (FT or PT) PT

Gross Earnings

4. 5. 6. Employer Name

Address

Address 2

City, State Zip

Municipality

Phone

Start Date

End Date

Status (FT or PT)

Gross Earnings

PLEASE NOTE:

All information received by the Tax Collector is considered to be CONFIDENTIAL and is only used for official purposes relating to the collection, administration and enforcement of the LOCAL SERVICES TAX.

I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION STATED ON AND

ATTACHED TO THIS FORM IS TRUE AND CORRECT:

SIGNATURE: DATE:

LST Exemption 10-07

mm/dd/yyyy

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

7. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 07/17/17 N

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

LOCK HAVEN UNIVERSITY APPLICANT ACKNOWLEDGEMENT AND CONSENT FOR CRIMINAL BACKGROUND CHECK

1. _______________________________________ hereby acknowledge and consent to the following: (PRINT NAME)

2. I have applied for a position with Lock Haven University and have been advised that all university employeesare required to satisfy the requirements of the Pennsylvania Child Protective Services Law (CPSL).

3. I acknowledge that CPSL requires a Pennsylvania State Police Criminal History Report, Pennsylvania Department of Human Services Child Abuse History Clearance and a Federal Bureau of Investigation Criminal History Report.

4. I further acknowledge that I will provide the original Federal Bureau of Investigation Criminal History Report(fingerprint report) to Human Resources at Lock Haven University.

5. I will use the provided payment code to submit my Pennsylvania Department of Human Services Child AbuseHistory Clearance report electronically, which will allow Lock Haven University access to the final report.

6. I understand that Human Resources at Lock Haven University will run the Pennsylvania State Police CriminalHistory report (e-PATCH) on my behalf and I am providing the following information for them to do so.

Full Name (print) _________________________________________________________________Date of Birth _________________________________________________________________Full Social Security Number _________________________________________________________________Aliases and/or Maiden Name _________________________________________________________________Race _________________________________________________________________Race is a required field in the Pennsylvania State Police application for the Criminal History Report. Failure to provide race onthis form will result in race being reported as unknown to the Pennsylvania State Police.

7. I understand that CPSL permits (but does not require) Lock Haven University to hire me on a provisional basisfor an approved time period not to exceed ninety (90) days.

8. I understand that during any authorized period of provisional employment/participation, I will not bepermitted to work alone with children and must work in the immediate vicinity of a permanent Lock HavenUniversity employee.

9. I understand that Lock Haven University may immediately terminate my provisional employment/participation should the Pennsylvania State Police, Pennsylvania Department of Human Services and/or the Federal Bureauof Investigation be unable to provide the required reports within the approved provisional period._____________________________________________ _________________________________________ SIGNATURE DATE _____________________________________________ __________________________________________ E-MAIL ADDRESS TELEPHONE NUMBER

APPLICANT FOR:

FACULTY STAFF STUDENT EMPLOYMENT VOLUNTEER DEPARTMENT: ________________ Approved by University Legal Counsel April 13, 2015

mm/dd/yyyy