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3

PORT JERVIS PUBLIC SCHOOLS 9 Thompson Street

P.O. Box 1104 Port Jervis, NY 12771

(845) 858-3100

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APPLICATION OF

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(Please Print)

Date of Application

POSITION PREFERENCE

First Choice: Level/Subject Area

Second Choice: Level/Subject Area

Third Choice: Level/Subject Area

PERSONAL DATA

Dr., Mr., Mrs., Ms.

Last First Middle ADDRESS: _________________ Telephone# ( ) _____~

City State Zip Code

Social Security# ______________ NYS Tchr's Ret. System#:, ______ (if available)

Are you a citizen of the United States? Yes No e-mail address below: Have you ever been convicted of a crime? __ Yes __No

EDUCATION AND PROFESSIONAL TRAINING

Name & Location of School Dates Attended Type of Diploma Earned High School

Name & Location ofSchool(s) Dates Attended Major Minor Degree Earned Undergraduate

Name & location of School(s) Dates Attended Area of # of Credits Degree Specialization Earned Earned

Graduate

CERTIFICATION

TYPE Valid in Date of # ofCertificate Copy Attached Perm, Prof, CQ State of Subject Area(s) Issuance YES NO

-----------

TEACHING EXPERIENCE

List most recent experience first. Include any substitute teaching and indicate as such. Dates Total Years Name & Location of School Specific Nature of Position If Full-Time

(Grade, Level, Subject, etc.) Position, Annual Salarv

Student Teachin~: If fewer than 3 vears of re~uiar full-time emolovment, include student teachin~ exoerience here. Dates Name & Location of School Subject and/or Grade Level

Have you ever been awarded tenure? YES -- NO -- District Date Have you ever been denied tenure? YES -- NO -- District Date

OTHER WORK EXPERIENCE

(Business, trades, summer occupations) Full-Time Evenings, Weekends,

Dates Finn or Institution Nature of Work Employment Summer Vacation Periods, etc.

EXTRACURRICULAR ACTIVITIES AND INTERESTS

Circle any of the following which you can coach or direct: Football Soccer Tennis Basketball Baseball Track Golf Dramatics Clubs Newspaper Yearbook Other _________________________

Language (s) other than English _________________________________

College or Community Activities --------------------------------~

Hobbies, Interests, Other Abilities ________________________________

MILITARY SERVICE

Inclusive Dates Nature of AssignmentHighest Rank Attained Mo-Yr. Mo-Yr.Branch of Service

Type of Separation ____________ Date _______ Present Status

REFERENCES

List at least three (3) references who have first-hand knowledge of your character, personality, scholarship, and teaching ability. If currentlv emoloved, include your oresent sunervisor.

Name Position Business Address Telephone Number (imoortant)

CANDIDATE'S STATEMENT

Applications often fail to convey a candidate's unique potential. Please comment in your own handwriting, in the space below, why your particular abilities/and personality are well-suited for the teaching profession.

ADDITIONAL MATERIALS TO BE SUBMITTED

Applications are only accepted via: mail or in person to the address below College Transcript - Copy or faxed to 845-858-3265 Resume Port Jervis City School District Certification if applicable Assistant Superintendent for Instruction Other evidence to support your application 9 Thompson Street

Port Jervis, NY 12771

CANDIDATE'S AFFIDAVIT

I certify that the information given in this application is correct. I understand that making a false statement on this application, or the withholding of information pertinent to my candidacy, may constitute grounds for dismissal.

Signature Date

The Port Jervis City School District, in compliance with the New York State Law, does not discriminate on the basis of age, color, national origin, sex, religion, marital status, or disability.

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NAME OF APPLICANT

The Board of Education has approved and adopted a differentiated pay scale for Substitute Teachers in the Port Jervis School District. A copy of this policy is summarized below. As you can see, it is important we have your most current information with regard to certification, degrees and/or credits.

( ) Indicates materials needed for your Substitute Teacher File

_·__ Completed Application Form

__ Copy of College Degree or Degree Certification

Copy ofNew York State Education Teacher Certification/Copy on file ,·

_ G...7'-'-\ "-'\ ~ jLL,tLGUA. ;~t ica.ii'..iU.k,1-t:

__ Completed Substitute Teacher Data Form

__ Documentation of Citizenship (See Enclosure)

__ Completed Federal and State tax forms

'.•-' I ·-, -. : ., - •' •· ". - , ,, <'•oe· ·-·' .' ' • '· , · ·'

Substitute Teachers form a valuable adjunct to the regular teaching staff. Their help and support affords a continuity to the educational process here in Port Jervis, To be ·eligible to substitute teach in the Port Jervis School District, the candidate must be in good physical condition, be of sound moral character, possess tact, and most importantly, genuinely enjoy the company ofyoung people.

Educational requirements fall into five categories:

CATEGORYA­ Fully certified or eligible for New York State Certification CATEGORYB- · Possession of a BAIMA or equivalent from an accredited college or

university (non-certified) CATEGORYC­ Possess 48 or more college credits CATEGORYRN - Registered Nurse (RN) CATEGORY LPN- Licensed Practical Nurse (LPN)

Substitutes for teaching positions will be called as follows: Persons in Category C will be called when Categories A and B have been totally utilized. Persons in Category B will be called when persons in Category A have been totally utilized.

The Substitute Pay Scale is as follows:

Category A $95 Category RN $110 Category B $90 Category LPN $95 Category C $80

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PORT JERVIS SCHOOL DISTRICT SUBSTITUTE TEACHER/HOME INSTRUCTOR UPDATE FORM

SCHOOL YEAR 2018 - 2019

NAME _____________ SOC. SECURITY NO.-~--------

ADDRESS ___________ TELEPHONE# ( ) _________

CELL PHONE# ( ) ________

EMERGENCY CONTACT INFORMATION: NAME ________________ RELATIONSHIP ____________ PHONE# ___________

CERTIFICATION

Certificate title St ate Permanent Professional Provisional Initial ______ Pending _____________

If Not Certified: Degree Level __________ Credit Hours

Interested in becoming a HOME TUTOR (Only if certified): YES NO

2ndGrade Level Preferred: (List 151, , 3'd choice): Have you ever been convicted of a felony crime?

Elementary (K-6) ____ YES___ NO ___ Middle School (7-8) ___ If yes: Date ____ State ----High School (9-12) ___

Grade Levels/ Areas You Do Not Wish to Sub In: E-Mail Address ------------

*College Student: YES__ NO__ College Level: ____________ * College students will not be called until they phone the substitute coordinator with available dates.

Days Available for Substituting: Monday __ Tuesday __ Wednesday __ Thursday __ Friday __

Applicant's Signature Date

Nick Pantaleone Date Approved Assistant Superintendent for Instruction

Return to: Terri Pagano, Port Jervis City School District, 9 Thompson St., Port Jervis, NY 12771

Business Office

SCHOOL Dl!TRICT 9 Thompson Street

Port Jervis, New York 12771

Phone(845) 858-3188 Fax(845) 858-3187

Retirement System Declaration Statement

I hereby acknowledge that I have been informed by the Port Jervis City School District, my employer, that as an employee not currently a member of the Retirement System who is or will be rendering less than full-time service, I may, as a matter of right, join the Retirement System. I further acknowledge that I understand under present law if I elect to join the Retirement System, I must complete a membership application which must be filed with the Retirement System in order to be effective. As a result ofjoining the Retirement System, I will be required to contribute, pursuant to Article 15, 3.5% of my salary to the Retirement System.

Please check one and return to School Business Office at 9 Thompson Street.

__. I understand my option and I do not want to join the Retirement System.

__ I understand my option and wish to join the Retirement system. I will complete a membership application at the School Business Office.

__ I am already a member of the Retirement system.

(Date) (Signature)

10/07

Lorelei Case Assistant Superintendent for Business

9 Thompson Street Port Jervis, New York 12771

Phone (845) 858-3I00 Xl5531 Fax (845) 858-3187

OATH OF ALLEGIANCE

I do hereby pledge and declare that I will support the Constitution of the United States and the

Constitution of the State of New York, and that I will faithfully discharge the duties of the position of

__________________according to the best of my ability.

Signature of Employee

Date

712011

ICE

LO

,--...ea••

em-rBen,cY

Name__________________

Position_________________

Building,________

Person To Contact in an Emergency

Name__________________

Relationship________________

Home Phone ________

Work Phone._________

Cell Phone _________

OPTIONAL - Medical Details

Doctor__________________

Doctor's Phone __________

Medical Conditions. ______________

Allergies_________________

Return Completed Form to Barbara Hamilton at the Business Office

Central Administration - Business Office Port Jervis 9 Thompson Street Port Jervis, New York 12771

SCROOI DISTRICT

Phone (845) 858-3100 X15537 Fax (845) 858-3187

All Public School Districts are subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order for us to comply with these laws, we are inviting employees to voluntarily self identify their race or ethnicity. Providing this information is strictly voluntary and refusal to do so will not subject you to any adverse treatment. All information obtained will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. Names are withheld when reporting information.

Please complete and return this form to Barbara Hamilton via interoffice mail in a sealed envelope.

___Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other spanish culture or origin regardless of race.

___White (not ofHispanic origin)-All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.

___Black or African American (Not Hispanic or Latino) - a person having origins in any of the black racial groups ofAfrica.

--~Asian (Not Hispanic or Latino)-A person 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.

___Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

___American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples ofNorth and South America (including Central America), and who maintain tribal affiliation or community attachment.

___Two or More Races (Not Hispanic or Latino) - Persons who identify with two or more racial categories named above.

Print Name Signature

Position

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------------------

----------------------------

Direct Deposit Authorization Payroll Dept.

Port Jervis City School District 9 Thompson Street

Po11 Jervis N.Y. 12771

EMPLOYEE NAME:. ___________-=-c---~--------------Please print

BUILDING: ______________________________~

I hereby authorize the Port Jervis School District to initiate credit entries and to initiate if necessary, debit entries and adjustments for any credit entries in error to my accounts indicated below and the depository named below.

Bank Name

Bank Address ____________________ -----------

Transit/ABA Number_'------------------(Must be 9 digits)

1st Account Number

Checking or Savings·--,----------------------------Percent to be deposited (Ex. 50%) ______________________

2nd Account Number Checking or Savings._____________________________ Percent to be deposited (Ex. 50%)._______________________ The total percent for account one and two must equal 100%

This authority is to remain in effect until The Port Jervis School District has received written notification from me of its termination in such time and in such a manner as to afford the Depository a reasonable opportunity to act on it.

Signature of employee ----------------------~Date,

A VOIDED CHECK MUST BE ATTACHED TO TIDSAUTHORIZATION

Form W-4 (2018) 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 2018 if both of the following apply.

• For 2017 you had a right to a refund of all federal income tax withheld because you had no tax liability, and

• For 2018 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 2018 expires February 15, 2019. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General Instructions If you aren't exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2018 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 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 2018. 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 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, 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 Other 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 Instructions Personal Allowances Worksheet Complete this worksheet on page 3 first to determine the number of withholding allowances to claim.

Line C. Head of household please note: Generally, you can 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 might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. 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, during the year.

Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don't qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub. 505. 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 income includes all of

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

Form W•4 Department 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.

0MB No. 1545-007 4

~@18 Your first name and mlddle lnitlal Last name 2 Your social security number

Home address (number and street or rural route) 3 D Single D Married D Married, but withhold at higher Single rate.

Note: lf married filing separately, check "Married, but withhold at higher Single rate,"

City or town, state, and ZIP code 4 If your last name differs from that shown on your social security card,

check here. You must call B00M772M1213 for a replacement card. ► D 5

6 7

Total number of allowances you're claiming (from the applicable worksheet on the following pages) 5f-

A d di tion a I amount, if any, you want withheld from each paycheck 6 ~+

l claim exemption from withholding for 2018, 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 ,1

• This year I expect a refund of all federal income tax withheld because I expect to have no tax liab;::il:,it,,.:.______[..:c"-"'"'-''-'-'-""'-"--''J 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. 102200 Form W-4 {2018)

2

IT-2104 ~ 5['fE E;;,;;;;;;n~itchholding Allowance Certificate ~ New York State • New York City• Yonkers

Your social security numberFirst name and middle initial last name

Permanent home address (numbar and street or rural route) Apartment number Single or Head of household D Married □ Married, but withhold at higher single rate □

City, village, or post office State ZIP code Note: If married but legally separated, mark an Xin the Single or Head ofhousehold box.

Are you a resident of New York City? ........... YesD No □ Are you a resident of Yonkers? ..................... Yes D No □ Complete the worksheet on page 3 before making any entries. 1 Total number of allowances you are claiming for New York State and Yonkers, if applicable (from line 18) ........... 1

22 Total number of allowances for New York City (from line 29) .................................................................................. Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.

3 New York Stale amount ................................................................ , ... , ................................................................... 3

4 New York City amount ........................................................................................................................................... 4 5 Yonkers amount .................................................................................................................................................... 5

I certify that I am entitled to the number of withholding allowances claimed on this certificate.

IEmployee's signature IDate

Penalty-A penally of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld from your wages. You may also be subject to criminal penalties.

Employee: detach this page and give it to your employer; keep a copy for your records.

Employer: Keep this certificate with your records. Mark an X in box A and/or box B to indicate why you are sending a copy of this form to New York State (see instructions):

A Employee claimed more than 14 exemption allowances for NYS ............ AD

B Employee is a new hire or a rehire... B D First date employee performed services for pay (mm-dd-yyyy) (see instr.):

Are dependent health insurance benefits available for this employee? ............. Yes D No D

If Yes, enter the date the employee qualifies (mm-dd-ww): I I Employer's name and address (Employer: complete this section only ifyou are sending a copy of /his form lo the NYS Tax Department.) Employer identification number

Instructions Changes effective for 2018 Form IT-2104 has been revised for tax year 2018. The worksheet on page 3 and the charts beginning on page 4, used to compute withholding allowances orto enter an additional dollar amount on line(s) 3, 4, or 5, have been revised. If you previously filed a Form IT-2104 and used the worksheet or charts, you should complete a new 2018 Form IT-2104 and give it to your employer.

Who should file this form This certificate, Form IT-2104, is completed by an employee and given to the employer to Instruct the employer how much New York State (and New York City and Yonkers) tax to withhold from the employee's pay. The more allowances claimed, the lower the amount of tax withheld.

If you do not file Form IT-2104, your employer may use the same number of allowances you claimed on federal Form W-4. Due to differences in tax law, this may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers. Complete Form IT-2104 each year and file it with your employer if the number of allowances you may claim

is different from federal Form W--4 or has changed. Common reasons for completing a new Form IT-2104 each year include the following:

You started a new job.

You are no longer a dependent. Your indlvidual circumstances may have changed (for example, you were married or have an additional child). You moved into or out of NYC or Yonkers.

You itemize your deductions on your personal income tax return.

You claim allowances for New York State credits.

You owed tax or received a large refund when you filed your personal income tax return for the past year. Your wages have increased and you expect to earn $107,650 or more during the tax year. The total income of you and your spouse has increased to $107,650 or more for the tax year. You have significantly more or less income from other sources or from another job. You no longer qualify for exemption from withholding.

Employment Eligibility Verification Department of Homeland Secnrity

U.S. Citizenship and Immigration Services

USCIS Form 1-9

0MB No. 1615-0047 Expires 08/31/2019

► START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically1

during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

§e,c;"tigpJ)Ll:fupf.9yije,.1 tjfqr111i:IJio.ij_~l"jcfAtte,st~tJ911 {E,f!'ip/aji~!.s mr1sLco.mpJet&•aIH~h}He;Hrst~afofitifpioyn1il]t",b~Wf§tl;i.fi(<fria6c_epJifJ{Ja/oh iJirfd .\ ~- . -- - -Last Name (Family Name) First Name (Given Name) Middle Initial

Address (Street Number and Name) Apt. Number City or Town

niis/gfi~e1uo.,-,•1 ~ft=ii&i F~iJo 1afer.t ·· _"_ .. _ \• r

Other Last Names Used (if any)

State ZIP Code

Date of Birth /mmlddlyyyy) U.S. Social Security Number

[I]J-[D-1 1111 Employee's E-mail Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

D 1. A citizen of the United States

D 2. A noncitizen national of the United States (See instructions)

D 3. A lawful permanent resident (Alien Registration Number/USCIS Number):

D 4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):

Some aliens may write "N/A" in the expiration date field. (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form /-9: An Alien Registration Number/USCIS Number OR Form /-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

OR 2. Form 1-94 Admission Number:

OR 3. Foreign Passport Number:

QR Code - Section 1 Do Not Write In This Space

Country of Issuance:

Signature of Employee Today's Date (mmlddlyyyy)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct. Signature of Preparer or Translator IToday's Date (mmlddlyyyy)

Last Name (Family Name) First Name (Given Name)

Address {Street Number and Name) City or Town State ZIP Code

Page I of3 Fmm I-9 I l/14/2016 N

USCISEmployment Eligibility Verification Form I-9

Department of Homeland Security 0MB No. 1615-0047

U.S. Citizenship and Immigration Services Expires 08/31/2019

List CList A OR List B AND Employment AuthorizationIdentity and Employment Authorization Identity

.,,- Document TitleDocument TitleDocument Title ts ,:'/

Issuing Authority Issuing Authority Issuing Authority ..• Document Number Document NumberDocument Number

l~ -

et Expiration Date /if any)(mmlddlyWY) Expiration Date (if any)(mmlddlywr)Expiration Date /if any)(mmlddlywr) t--'

i1Document Title if~';, ,;:,_ .!..- Additional InformationIssuing Authority h i.: i~\Document Number -,-,;

ii fj

Expiration Date /if any)(mmlddlyyyy) +sc: -a'=-'>--' ,-

Document Title [:"' t~~

Issuing Authority 'f'.S

~Ii c-..Document Number -~~

I:;Expiration Date /if any)(mmlddlyWY)

:t

QR Code - Sections 2 & 3 Do Not Write In This Space

Certification: I attest1 under penalty of perjury, that (1) I have examined the docurnent(s) presented by the above-named employee,

(2) the above-listed document{s} appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.

The employee's first day of employment (mmlddlYYW}: _______ (See instructions for exemptions)

Signature of Employer or Authorized Representative IToday's Date(mmlddlyyyy) ITitle of Employer or Authorized Representative

Last Name of Employer or Authorized Representative IFirst Name of Employer or Authorized Representative IEmployer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or TownI State ZIP Code1

!.~N~~i11wrfr{~f~tat1ih•~n~;Rll~i[e~"~c\i'~&e1~f~i!larfl[#ilftfi!iefl~malt>~ft:C,r~~~?;~v!;t1?:!f!f;i~Jff;~;flWl\ft[fi~lf,if,~;?ll Last Name (Family Name) First Name (Given Name) IMiddle Initial Date (mmlddlyyyy)

C:· lf t_hE(~-~pl~Ye:e1s_pr~v_iqj;S -fJr8_1i( of,~1TlplO~rnen1 a~~i,o:r:izat_i_O_rj 'pa~.e.~~ite9 ;' .pf9~\~_e !}ie___lh_.f9.r_["[i_at~Q-~ rOr ~t~_e_··-~_o_s_~-rr,~nt ,or-_r_ec~ip} :_~haf_e,:?t~f?_l_ish_~~---_: ~- ::· .. _..,_.. .' co'ntinllfi]g.._~_mp1~Y.ment8L!Jh6riZ8p_o_r\ .iq th_e s_pa_ce p~9victed:_6el0~.:- -_;_ ,c;,-:_.-_·. :-:-'. 0):-·.\"·=~--~- .' :-·.:,. ::,_·,\:· _:::•/.-::· ';_-,_-~_-~} __ ;;-, -.-;_·_,;,_·,_,- :,i·•--_;:,._:;;,_,;-'....-:~- ' - _,t >·:i:: :·,,, -~ ,. _,_;_-::. ~,.-----::-.::.- -Document Title IDocument Number IExpiration Date (if any) (mmldd/yyyy)

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative Today's Date (mmlddlyyyy) Name of Employer or Authorized Representative

Page 2 of3Fonnl-9 ll/14/2016N

LISTS OF ACCEPTABLE DOCUMENTS All 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.

LISTA LIST B LISTC'.-I Documents that Establish

Both Identity and Documents that Establish Documents that Establish

Identity Employment Authorization Employment Authorization

• AND

1. A Social Security Account Number State or outlying possession of the

1. U.S. Passport or U.S. Passport Card ·•· 1. Driver's license or ID card issued by a card, unless the card includes one of

2. Permanent Resident Card or Alien the following restrictions:United States provided it contains aRegistration Receipt Card (Form 1-551) photograph or information such as (1) NOT VALID FOR EMPLOYMENT

name, date of birth, gender, height, eye (2) VALID FOR WORK ONLY WITH 3. Foreign passport that contains a color, and address

INS AUTHORIZATION 1-551 printed notation on a machine-temporary 1-551 stamp or temporary

2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH readable immigrant visa government agencies or entities, OHS AUTHORIZATION

provided it contains a photograph or 4. Employment Authorization Document 2. Certification of Birth Abroad issuedinformation such as name, date of birth,

that contains a photograph (Form by the Department of State (Form gender, height, eye color, and address FS-545)1-766) ..

3. School ID card with a photograph 3. Certification of Report of Birth5. For a nonimmigrant alien authorized

l'f"il 4_ issued by the Department of StateVoter's registration cardto work for a specific employer (Form DS-1350) because of his or her status:

5. U.S. Military card or draft record 4. Original or certified copy of birtha. Foreign passport; and

certificate issued by a State,':F 6. Military dependent's ID card b. Form 1-94 or Form l-94A that has .... county, municipal authority, orthe following: I: . 7. U.S. Coast Guard Merchant Mariner ,. territory of the United States

; Card(1) The same name as the passport; bearing an official seal and Native American tribal document\ 8. 5. Native American tribal document

(2) An endorsement of the alien's I•• 9. Driver's license issued by a Canadiannonimmigrant status as long as 6. U.S. Citizen ID Card (Form 1-197). government authority

not yet expired and the that period of endorsement has

7. Identification Card for Use of proposed employment is not in For persons under age 18 who are Resident Citizen in the United conflict with any restrictions or unable to present a document States (Form 1-179) limitations identified on the form. listed above:

8. Employment authorization 6. Passport from the Federated States of document issued by the 10. School record or report card

Micronesia (FSM) or the Republic of Department of Homeland Security the Marshall Islands (RMI) with Form 11. Clinic, doctor, or hospital record 1-94 or Form l-94A indicating

12. Day~care or nursery school recordnonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI •

·•·

Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Form 1-9 11/14/2016 N Page 3 of3