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BONHAM ISD Requirements for

Maintenance/Transportation/Food Service Personnel

Name ____________________________________________________________________

_____ Application – Signed/Dated

_____ Application Addendum for Bus Drivers (if applicable)

_____ Drug Abuse Policy

_____ District Acceptable Use of Computers Policy

_____ Permission for Criminal History Record Check Clear ____________________

_____ Social Security Information Form

_____ W-4 Form

_____ Employee Emergency Information Form

_____ Employee Information Release Form

_____ Direct Deposit Form

_____ Ethnicity and Race Questionnaire

_____ Texas Workers’ Compensation Act Notice

_____ Driver’s License

_____ Social Security Card

_____ Fingerprinting

_____ References

_____ Job Description ~ Signed/Dated

_____ Employee Handbook Acknowledgement

_____ Form I-9

_____ Badge

_____ Benefits – Payroll

BONHAM INDEPENDENT SCHOOL DISTRICT P.O. Box 490

Bonham, TX 75418

Employment Application for Service and Support Personnel

We consider applicants for all positions without regard to race, color, national origin, age, religion, sex, marital or veteran status, the presence of a medical condition, disability, or any other legally protected status.

An Equal-Opportunity Employer

Pers

onal

Dat

a

Date of Application ______________________ Social Security No. ________________________________________

Name _______________________________________________________________________________________________

Current Address ____________________________________________________________________________________

Other address where you may be reached____________________________________________________________

Phone No. __________________________________________________________________________________________

Posi

tion

Dat

e

Position for which you are applying __________________________________________________________________

Aide: Are you interested in becoming a teacher? _____Yes _____No

Type of Employment: Full-time _____ Part-time _____ Summer Only _____

Date Available ____________________

Former Bonham ISD Employee? _____Yes _____No

Edu

cati

on/T

rain

ing

Check highest level attained. ( ) Not High School Graduate (Circle last grade completed) 1 2 3 4 5 6 7 8 9 10 11 12 ( ) High School Graduate ( ) GED ( ) Less than two years college ( ) Two or more years college ( ) Bachelor’s Degree ( ) Master’s Degree ( ) Other training or education _________________________________ Licenses/certifications held _________________________________________________________________________ Schools Attended: List all applicable information

Name of School and Location

Course of Study Major/Minor Fields

Diploma, Degree, Certificate

Year of Graduation (College Only)

Wor

k E

xper

ienc

e Please provide a complete listing of all jobs or positions you have held in the past 10 years. List most recent first. Attach additional sheets if necessary.

Employer, Address, Phone No. Position/Title Dates Employed Reason for Leaving

Spec

ial S

kill

s

List specific skills and/or any machines or equipment you can operate. Include typing speed and number of years experience. 1. _____________________________________________ 4. _____________________________________________ 2. _____________________________________________ 5. _____________________________________________ 3. _____________________________________________ 6. _____________________________________________

Gen

eral

Inf

orm

atio

n

• Do you have a relative who is a member of the Bonham ISD Board of Education? _____ Yes _____ No If yes, please give the name of relative and relationship: ___________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

• Have you ever received deferred adjudication or served probation for any offense? _____ Yes _____ No If yes, please explain _____________________________________________ _____________________________________________________________________________________________

• Have you ever been convicted of a felony or offense involving moral turpitude (including, but not limited to theft, rape, murder, swindling and indecency with a minor)? _____ Yes _____ No If yes, please state where, when and the nature of the offense ______ ______________________________________________________________________________________________ ______________________________________________________________________________________________ (Conviction of a felony is not an automatic bar to employment. The district will consider the nature, date, and relationship between the offense and the position for which you are applying.)

Ref

eren

ces

Please list below references who may be contacted regarding your work history. Please include all managers/supervisors at the last two employing organizations who evaluated or supervised your performance.

Full name of Reference

School District/Firm

Name

Mailing Address Position/Title

Phone No. (include area

code)

Ver

ific

atio

n

I hereby affirm that all information provided in this application is true and accurate to the best of my knowledge and understand that any deliberate falsifications, misrepresentations, or omissions of fact may be grounds for rejection of my application or dismissal from subsequent employment. I authorize the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all such parties from any liability damage that may result from furnishing same to you. I understand that the district is required by Texas Education Code 21.917 to obtain criminal history record information on applicants selected for employment. This application becomes the property of the district. The district reserves the right to accept or reject it. This application shall be considered active for a period of time not to exceed one year. Any applicant wishing to be considered for employment beyond this time period may contact Bonham ISD, P.O. Box 490, Bonham, TX 75418. ________________________________________________________ ______________________________ Signature of Applicant Date

EMPLOYMENT PRACTICES DC (EXHIBIT)

EXHIBIT D

EMPLOYMENT APPLICATION ADDENDUM FOR SCHOOL BUS DRIVERS

Each person who applies to be a bus driver must provide the following information at the time of application. Note: Bus drivers must pass a physical examination and drug test.

An Equal Opportunity Employer*

Personal Data

Name Phone number ---------------- ----------Hours available for work Driver's license number _______ Type ___ _

Do you have a Texas School Bus Driver Training Certificate? D Yes D No

Have you ever had a driver's license suspended, revoked, or cancelled? D Yes D No

If you answered yes, explain----------------------

Are there any criminal charges or proceedings pending against you? D Yes D No


Have you ever been convicted of, pied guilty or no contest (nolo contendre) to, or received probation, suspension, or deferred adjudication for any traffic violation? D Yes D No

If yes, state where, when, and the nature of the offense------------

In the past two years, have you failed an employer's alcohol or drug test? D Yes D No


DATE ISSUED: 4/26/2010 UPDATE 36 DC(EXHIBIT}-RRM

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EMPLOYMENT PRACTICES

Driving Experience

DC (EXHIBIT)

Provide your work history information for the past 10 years on all jobs for which you were a driver of a commercial motor vehicle. List the most recent experience first. Continue on another sheet if necessary.

Employer address and phone Kind of work Dates Reason for

employed leaving

Verification

I hereby affirm that all the information provided in this application is true and accurate to the best of my knowledge and I understand that any deliberate falsifications, misrepresentations, or omissions of fact may be grounds for rejection of my application or dismissal from subsequent employment.

I understand that the District is required by Title 37 Texas Administrative Code §14.14(b) to review my complete driving record, is required by federal regulations to obtain alcohol and drug testing results from previous employers for two years prior to this application, and required by Texas Education Code §22.0833 and Transportation Code §521.022 (f) to conduct a criminal history record check.

Furthermore, I authorize the information I've provided to be used, authorize previous employers to be contacted for investigative purposes, and release all parties from any liability for damage that may result from furnishing information to you.

Signature Date

*Applicants for all positions are considered without regard to race, color, sex (including pregnancy), national origin, religion, age, disability, genetic information, veteran or military status, or any other legally protected status.

DATE ISSUED: 4/26/2010 UPDATE 36 DC(EXHIBIT)-RRM

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DRUG ABUSE POLICY OF BONHAM INDEPENDENT SCHOOL DISTRICT

1. STATEMENT OF PUROPOSE AND SCOPE

BONHAM INDEPENDENT SCHOOL DISTRICT recognizes that alcohol and drug abuse in the work place has become a major concern. We believe that by reducing drug and alcohol abuse, we will improve the safety, health and productivity of employees. The object of our drug abuse policy is to provide a safe and healthy work place for all employees, prevent accidents and comply with Section 7.10 of the Texas Workers' Compensation Act.

The use, possession, sale, transfer, purchase or being under the influence of drugs by employees at any time on company premises or while on company business is prohibited. The illegal use of any drug is prohibited. Employee must not report for duty or be on company property while under the influence of, or have in their possession while on company property, any drug.

As a condition of employment, employees will notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after such conviction.

2. DEFINITION OF DRUG

For the purpose of this policy, the term "drug" wherever it appears in this policy statement, includes alcoholic beverages as well as inhalants and illegal drugs.

3. CONSEQUENCES OF VIOLATING THE DRUG ABUSE POLICY

Violation of this drug abuse policy will result in one of the following forms of corrective action: Immediate discharge, suspension, probation, oral warning or written warning. In arriving at a decision for proper action, the seriousness of the infraction, the past record of the employee, and the circumstances surrounding the matter will all be taken into consideration.

4. TREATMENT PROGRAMS AND EMPLOYEE INSURANCE

While we do not sponsor or endorse any specific drug treatment programs, such programs are available through public and private health care facilities in our area. Affected employees are encouraged to seek assistance for themselves and their dependents. The group health insurance offered to employees and their dependents provides limited coverage for expenses related to drug treatment programs. See your supervisor or refer to the plan description for details.

5. EDUCATION AND TRAINING PROGRAMS

We do not offer, nor require participation in, drug and alcohol abuse education and training programs. However, various public and private facilities in our area offer such programs and affected employees are encouraged to seek assistance.

6. DRUG TESTING

We do not require drug testing as a condition for employment.

(Signature of Employee) (Date Signed)

DISTRICT ACCEPTABLE USE OF COMPUTERS POLICY For Employees

Bonham ISD believes technology and the Internet offer vast, diverse, and unique resources to students. In addition, state requirements dictate that classes incorporate technology components. Employees will have access to the Internet through the District’s networked computers. The District will notify the employees about the District network and the policies governing its use. By providing this service, Bonham ISD endeavors to promote educational excellence by facilitating resource sharing, instructional innovation, and extended communication in a rich learning environment. With thoughtful and responsible use of technology, Bonham ISD offers students and teachers the opportunity to engage in true 21st Century classroom instruction.

Access to computers and people all over the world also brings the availability of material that may not be of educational value in the context of a school setting. Bonham ISD filters Internet content in compliance with the Children’s Internet Protection Act (CIPA); however, it is impossible to control all materials, and an industrious user may still discover objectionable information. Bonham ISD believes that the educational benefits of the Internet far outweigh the possibility that users may access material that is not consistent with the Learning Outcomes of the District.

Access to the District’s technology resources is a privilege, not a right. Therefore, employee access may be revoked for just cause. If an employee chooses to use District resources for finding information that will be of assistance in learning and producing material for educational purposes, the consequence will be continued access to the Internet. If an employee chooses to abuse these resources by, for example, accessing sites that are disallowed, the consequence will be suspension or termination of access privileges in addition to other consequences set forth in the district’s personnel policy. Use of the District’s network, resources, hardware, etc. constitutes acceptance of the policies contained herein.

Definition of District Technology Resources

District Technology consists of district computer systems, networks, hardware, peripherals, and software. This may include, but is not limited to, computer hardware, operating system software, application software, stored texts, data files, electronic mail, databases, the Internet, CD-ROM, optical media, clip art, digital images, digitized information, communications technology, and new technologies as they become available. The District may monitor all technology resource activity.

Guidelines

The following guidelines shall govern students’ use of District technology resources. Violation of these guidelines will constitute a violation of the District’s Acceptable Use Policy.

1. Personal Safety/Privacy

a. Use of District systems, including Internet use, is not considered private and may be monitored by the District.

b. Users will not post personal contact information about themselves or others. Personal contact information includes address, telephone, school address, work address, etc.

c. Users will not repost a message that was sent to them privately without permission of the person who originally sent the message.

d. Users will promptly disclose to administrative school employees any message they receive that is inappropriate or makes them feel uncomfortable.

e. Users will not participate in social networking sites such as MySpace or Facebook using District resources or while on school grounds. In certain situations, teachers may request that their classes be granted access to educational sites that allow for collaborative learning. Employess will acknowledge and use caution when interacting with students electronically outside the school

Acceptable Use of Computers Policy for BISD

environment. Such interaction may include activities like “friending” and/or texting. f. Users will not directly access any “chat room” or instant messaging service through any computer

in the Bonham ISD. Making a connection to such sites does not happen by accident, but should anyone unintentionally find him/herself in a “chat room” site through some other connection, that person must immediately disconnect from that site.

h. Users will not access resources, files, or data of another user without authorization, nor will the user attempt to harm resources, files or data of another user or of the District.

i. Taking unapproved videos, photos, or audio recordings of people and events at school and/or the posting of such recordings on any website without explicit written permission from the District is strictly forbidden. This includes, but is not limited to, recordings/photos made with cell phones.

2. Illegal Activities

a. Users will not attempt to gain unauthorized access to the District system or to any other computer system through the District Network or go beyond their authorized access. This includes attempting to log in through another person’s account or access another person’s files. These actions are illegal, even if only for the purposes of “browsing”.

b. Users will not make deliberate attempts to disrupt the computer system performance or destroy data by spreading computer viruses or by any other means.

c. Users will not use the District equipment to engage in any other illegal act, such as arranging for a drug sale or the purchase of alcohol, engaging in criminal gang activity, threatening the safety of persons, etc.

3. System Security

a. Users are responsible for the use of their individual account and should take all reasonable precautions to prevent others from being able to use their account. Under no conditions should a user provide his/her password to another person. Login and password information for District resources should not be posted where others can view it.

b. Users will immediately notify the system administrator or campus administrator if they have identified a possible security problem. Users will not look for security problems because this may be construed as an illegal attempt to gain access.

c. Users will avoid the inadvertent spread of computer viruses by following the District virus protection procedures if they download information/software.

d. Bonham ISD filters Internet resources in accordance with the Children’s Internet Protection Act (CIPA). Users shall not attempt to bypass or disable district content filters. This includes the use of anonymous proxies.

e. Teachers will not allow students to use a computer on which the teacher is currently logged in as him/herself. Students should only be allowed to use a computer that is connected to the District network with a student login.

4. Inappropriate Language

a. Restrictions against inappropriate language apply to public messages, private messages, and material posted on Web pages.

b. Users will not use obscene, profane, lewd, vulgar, rude, inflammatory, threatening, or disrespectful language.

c. Users will not engage in personal attacks, including prejudicial or discriminatory attacks. d. Users will not harass another person. Harassment is persistently acting in a manner that

distresses or annoys another person. If a user is told by a person to stop sending them messages, they must stop.

e. Users will not knowingly or recklessly post false or defamatory information about a person or organization.


5. Respecting Resource Limits a. Users will use the system only for educational and professional or career development activities and

limited self-discovery activities. b. Users will not download large files unless absolutely necessary. If necessary, users will download

the file at a time when the system is not being heavily used and immediately remove the file from the system computer to his or her personal computer or storage device.

c. Users will not post chain letters or engage in “spamming”. Spamming is sending an annoying or unnecessary message to a large number of people.

d. Users will check their email frequently, delete unwanted messages promptly, and stay within their email quota.

e. Users will subscribe only to high quality discussion group mail lists that are relevant to their education or professional/career development.

6. Plagiarisms and Copyright Infringement

a. Users will not plagiarize works that they find on electronic media, including the Internet. Plagiarism is taking the ideas or writings of others and presenting them as if they were original to the user.

b. Users will respect the rights of copyright owners. Copyright infringement occurs when an individual inappropriately reproduces a work what is protected by a copyright. If a work content language specifies acceptable use of that work, the user should follow the expressed requirements. If the user is unsure whether or not they can use a work, they should request permission from the copyright owner.

7. Inappropriate Access to Material

a. Users will not use the District computers to access material that is profane or obscene (pornography), that advocates illegal acts, or that advocates violence or discrimination towards other people (hate literature). For employees, a special exception may be made for hate literature if the purpose of such access is to conduct research.

b. If a user inadvertently accesses such information, they should immediately disclose the inadvertent access in a manner specified by their school. This may help protect users against an allegation that they have intentionally violated the Acceptable Use Policy.

8. Software and Personal Hardware Usage

a. Employees will only use district-approved and owned software. The Director of Technology must approve all software. The use or installation or downloading of unapproved software is prohibited. This includes the use of software from “flash drives” or other memory devices.

Bonham ISD makes no warranties of any kind, whether expressed or implied, for the service it is providing. We assume no responsibility or liability for any phone charges, line costs, or usage fees, nor for any damages a user may suffer. This includes loss of data resulting from delays, non-deliveries, or service interruptions caused by accident or your errors or omissions. Use of any information obtained via the Internet is at your own risk. We specifically deny any responsibility for the accuracy or quality of information obtained through its services.

All communication and information accessible via the computer resources shall be regarded as private property. However, people who operate the system may review files and messages to maintain system integrity and insure that users are using the system responsibly. Messages relating to or in support of illegal activities may be reported to the authorities.

Rules of Netiquette and General Internet Use 1. Never give out personal information - including your full name (first names are best), home phone

number, home address, or other data - anywhere on the Internet, including your email.


2. Be concerned about getting email messages from anyone asking you for personal information, attempting to arrange secret meetings, or engaging in other activities which might suggest a problem or an unsafe condition.

3. Always ask for permission to use pictures or text from someone's online site, and then give the person credit in your bibliography.

4. Treat other online users as you would like to be treated. 5. Treat school computers like you would treat your own - with respect. 6. Protect your password if you have been given one. Keep it to yourself.

7. While online, stay focused on the topic you are researching. The Internet is an excellent educational

resource - use it responsibly.

8. Ask for help if you are having problems. Write down any error messages that appear when you try to do something.

9. Keep the area around a computer clean and free of food and drink.

10. Never use a computer to harm other people.

________________________________________ ______________________ Employee Signature Date


Revised 10/23/2015

BONHAM INDEPENDENT SCHOOL DISTRICT Consent to Perform Investigative Criminal History Record Check

(In Compliance with the FCRA - Fair Credit Reporting Act)

______________________________________________________________________________________________________ Last Name First Name Middle Initial or name ______________________________________________________________________________________________________ Maiden or other name(s) aka (also known as) used in any and all other records of birth or residence. ______________________________________________________________________________________________________ Address Apartment or # ______________________________________________________________________________________________________ City County State Zip ______________________________________________________________________________________________________ Date of Birth Social Security Number *Gender *Race ______________________________________________________________________________________________________ Driver’s License Number Issuing State *Weight *Height (feet/inches) *To be used for criminal history checks only & not a part of the personnel file. In connection with my application for employment, volunteerism, or my continued employment, I have been advised and I hereby consent and authorize Bonham ISD and its agent, at any time during or subsequent to my application process or employment, to conduct an investigative consumer background report that may include, but is not limited to, a criminal record check, employment and education verifications; personal references; personal interviews; and driving record. I do hereby consent to Bonham ISD the use of any information provided on this form during the application and/or employment process in performing the background report. Bonham ISD has informed me that I have the right to review and challenge any negative information that would adversely impact a decision to offer employment/volunteerism. I agree to release, indemnify and hold harmless Bonham ISD and any reporting agency Bonham ISD uses with regard to any information reported by the reporting agency. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained from a consumer reporting agency. If so, I will be notified and given the name, address, and phone number of the agency which provided the information. In addition, I have been informed that I will have a reasonable opportunity to clear up any mistaken information reported within a reasonable time frame established within the sole discretion of Bonham ISD. Under the fair credit reporting act, I have been advised that upon request I will be provided the name, address and telephone number of the reporting agency as well as the nature, substance and source of all information. I acknowledge that facsimile, copy or email shall be as valid as the original. The following are my responses to questions about my criminal history (if any). 1. Have you ever been convicted or plead guilty before a court for any federal, state or municipal criminal offense? (exclude minor

traffic misdemeanors). YES ________ NO _________ If YES, please provide details below:

State: County: Date of Offense: / / Details of Conviction:

2. Have you ever received deferred adjudication or similar disposition for any federal, state or municipal offense? YES ________ NO ________ If YES, provide details below:

State: County: Date of Offense: / / Details of Conviction:

3. Have you ever received probation or community supervision for any federal, state or municipal offense?

Revised 10/23/2015

YES ________ NO ________ If YES, provide details below: State: County: Date of Offense: / / Details of Supervision:

4. Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States?

YES ________ NO ________ If YES, provide details below: Country: City: Date of Offense: / / Details of Conviction:

5. As of the date of this consent form, do you have any pending charges against you?

YES _______ NO _______ If YES, please provide details below: State: County: Date of Offense: / / Details of pending charges:

Personal Statement I hereby certify that all information provided in this consent form is true, correct and complete. If any information proves to be incorrect or incomplete, I understand that grounds for canceling of any and all offers of employment / volunteerism will exist and may be used at the discretion of Bonham ISD. Signed this ___________________ day of ________________________________________, 20_______. Applicant (Print Name) __________________________________________________________________ Applicant Signature _____________________________________________________________________ Bonham ISD does not discriminate on the basis of sex, disability, race, color, age or national origin in its educational programs, activities, or employment as required by Title IX, Section 504 and Title VI. ________________________________________________ _____________________________________ Bonham ISD Administrator Requesting Check Date ________________________________________________ _____________________________________ Bonham ISD Official Performing the Criminal History Check Date ________________________________________________ _____________________________________ Results Date

Revised 10/23/2015

DPS Computerized Criminal History (CCH) Verification (AGENCY COPY)

I, ________________________________________, have been notified that a Computerized Criminal APPLICANT or EMPLOYEE NAME (Please print)

History (CCH) verification check will be performed by accessing the Texas Department of Public Safety Secure Website

and will be based on name and DOB identifiers I supply.

Because the name-based information is not an exact search and only fingerprint record searches represent true

identification to criminal history, the organization conducting the criminal history check for background screening is not

allowed to discuss any criminal history record information obtained using the name and DOB method. Therefore, the

agency may request that I have a fingerprint search performed to clear any misidentification based on the result of the

name and DOB search.

For the fingerprinting process I will be required to submit a full and complete set of my fingerprints for analysis

through the Texas Department of Public Safety AFIS (Automated Fingerprint Identification System). I have been made

aware that in order to complete this process I must make an appointment with L1 Enrollment Services, submit a full and

complete set of my fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to the

fingerprinting services company, L1 Enrollment Services.

Once this process is completed and the agency receives the data from DPS, the information on my fingerprint

criminal history record may be discussed with me.

(This copy must remain on file by your agency. Required for future DPS Audits)

______________________________ Signature of Applicant or Employee

____________________ Date

BONHAM INDEPENDENT SCHOOL DISTRICT __________________________________________________ Agency Name (Please print)

DEBBIE HORTON __________________________________________________ Agency Representative Name (Please print)

__________________________________________________ Signature of Agency Representative

____________________ Date

Please: Check and Initial each Applicable Space

CCH Report Printed: YES NO ____________ initial

Purpose of CCH: _____________________________

Hire Not Hired ____________ initial

Date Printed: ___________ ____________ initial

Destroyed Date: ________ ____________ initial

Retain in your files

Form SSA-1945 (01-2013)

Information about Social Security Form SSA-1945 Statement Concerning Your Employment in a Job Not Covered by Social Security

New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires State and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not covered under Social Security. The statement explains how a pension from that job could affect future Social Security benefits to which they may become entitled.

Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential effects of two provisions in the Social Security law for workers who also receive a pension based on their work in a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker’s Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social Security benefit received as a spouse, surviving spouse, or an ex-spouse.

Employers must:

• Give the statement to the employee prior to the start of employment;

• Get the employee’s signature on the form; and

• Submit a copy of the signed form to the pension paying agency.

Social Security will not be setting any additional guidelines for the use of this form.

Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.gov/online/ssa-1945.pdf. Paper copies can be requested by email at [email protected] or by fax at 410-965-2037. The request must include the name, complete address and telephone number of the employer. Forms will not be sent to a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. The forms are available in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.

Form SSA-1945 (01-2013) Destroy Prior Editions

Social Security Administration

Statement Concerning Your Employment in a Job Not Covered by Social Security

Employee Name Employee ID#

Employer Name Employer ID#

Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be affected.

Windfall Elimination Provision Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as a result of this provision is $395.50. This amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall Elimination Provision.”

Government Pension Offset Provision Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension.

For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “Government Pension Offset.”

For More Information Social Security publications and additional information, including information about exceptions to each provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.

I certify that I have received Form SSA-1945 that contains information about the possible effects of the Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social Security Benefits.

Signature of Employee Date

Form W-4 (2017)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. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2017 expires February 15, 2018. See Pub. 505, Tax Withholding and Estimated Tax.Note: If another person can claim you as a dependent on his or her tax return, you can’t claim exemption from withholding if your total income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:• Is age 65 or older,

• Is blind, or

• Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions don’t apply to supplemental wages greater than $1,000,000.Basic instructions. If you aren’t exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

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 may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2017. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You’re single and have only one job; or• You’re married, have only one job, and your spouse doesn’t work; or . . .• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . DE Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . EF Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you have two to four eligible children or less “2” if you have five or more eligible children. • If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child. G

H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) ▶ H

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate▶ Whether you are 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

20171 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, but legally separated, or spouse is a nonresident alien, check the “Single” box.

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

check here. You must call 1-800-772-1213 for a replacement card. ▶

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2017, 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 lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2017)

Form W-4 (2017) Page 2 Deductions and Adjustments Worksheet

Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.1 Enter an estimate of your 2017 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state

and local taxes, medical expenses in excess of 10% of your income, and miscellaneous deductions. For 2017, you may have to reduce your itemized deductions if your income is over $313,800 and you’re married filing jointly or you’re a qualifying widow(er); $287,650 if you’re head of household; $261,500 if you’re single, not head of household and not a qualifying widow(er); or $156,900 if you’re married filing separately. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $12,700 if married filing jointly or qualifying widow(er)$9,350 if head of household . . . . . . . . . . .$6,350 if single or married filing separately

} 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2017 adjustments to income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2017 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2017 nonwage income (such as dividends or interest) . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)Note: Use this worksheet only if the instructions under line H on page 1 direct you here.1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 12 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 3

Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $9 Divide line 8 by the number of pay periods remaining in 2017. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2017. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $

Table 1Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $7,000 07,001 - 14,000 1

14,001 - 22,000 222,001 - 27,000 327,001 - 35,000 435,001 - 44,000 544,001 - 55,000 655,001 - 65,000 765,001 - 75,000 875,001 - 80,000 980,001 - 95,000 10

95,001 - 115,000 11115,001 - 130,000 12130,001 - 140,000 13140,001 - 150,000 14150,001 and over 15

All Others

If wages from LOWEST paying job are—


$0 - $8,000 08,001 - 16,000 1

16,001 - 26,000 226,001 - 34,000 334,001 - 44,000 444,001 - 70,000 570,001 - 85,000 685,001 - 110,000 7

110,001 - 125,000 8125,001 - 140,000 9140,001 and over 10

Table 2Married Filing Jointly

If wages from HIGHEST paying job are—


$0 - $75,000 $61075,001 - 135,000 1,010

135,001 - 205,000 1,130205,001 - 360,000 1,340360,001 - 405,000 1,420405,001 and over 1,600

All Others

If wages from HIGHEST paying job are—


$0 - $38,000 $61038,001 - 85,000 1,01085,001 - 185,000 1,130

185,001 - 400,000 1,340400,001 and over 1,600

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

Employee’s Name: ______________________________

The following information will be confidential and used only in an emergency.

Emergency Contacts

Name: ____________________________________________________

Address: ___________________________________________________

Phone# (home & work): ________________________________________

Cell Phone#: ________________________________________________

Relationship: ________________________________________________

Name: ____________________________________________________

Address: ___________________________________________________

Phone# (home & work): ________________________________________

Cell Phone#: ________________________________________________

Relationship: ________________________________________________

Medical History

Please list any medical information that may be helpful in an emergency situation including:

Physician’s Name/Phone#: ________________________________________

Drug Allergies: _________________________________________________

Any other helpful information:_______________________________________

____________________________________________________________

____________________________________________________________

4/10/2013

Bonham Independent School District Employee Information Release Form

Personal information shall be allowed public access as indicated below:

Home address ________ ________

Telephone Number ________ ________

Email Address ________ ________

I understand that I may make a written request at any time to open or close access to the above information.

______________________________ ______________________________ Employee Name (please print) Campus/Department

______________________________ ______________________________ Employee Signature Date

This form must be completed and returned to Human Resources no later than fourteen (14) days after the beginning of employment with Bonham Independent School District.

No Yes

REVISED 9/26/2014

ACCOUNT # 2 Start ________ Stop ________ Change Amount ________

Bank Name _________________________________________________

Bonham Independent School District

DIRECT DEPOSIT AUTHORIZATION

Please print clearly.

Employee Name

Bonham ISD utilizes Direct Deposit for payroll checks to our employees. Split deposits to checking and savings accounts are available. Please read, complete, sign, and date the authorization below.

I would like my payroll check Direct Deposited into ONE ACCOUNT.

I would like my payroll check Direct Deposited into MORE THAN ONE ACCOUNT.

A voided check(s) must be attached in order to verify bank information

NET PAY ACCOUNT Start _ Stop

Bank Name _

Bank Address _

Routing # _

Account # Type Account Amount $

ACCOUNT # 2 Start _ Stop Change Amount _

Bank Name _

Bank Address _

Routing # _

Account # Type Account Amount $

I HEREBY AUTHORIZE Bonham ISD to Direct Deposit the payment described above to my account(s) at the financial institution(s) named above. Bonham ISD is authorized to adjust deposits made to my account in error. I will not hold the financial institution named above liable for any erroneous deposits or adjustments made by Bonham ISD.

This authorization is to remain in effect until Bonham ISD has received written notification from me of its termination in such time and in such manner as to afford Bonham ISD and the depository a reasonable opportunity to act on it.

Employee Signature

Date ___

Revised 8/1/2017

3/18/2016

Notice of Employer Rights and Responsibilities Texas Workers’ Compensation Act

Notice of Coverage or Change in Coverage:

Bonham Independent School District must post the following notices in the workplace:

• BISD has workers’ compensation insurance and provides the name of the workers’ compensation insurance carrier: Texas Association of School Boards

• The Commission has staff to explain employees’ rights and responsibilities and to help resolve disputes about their claims: 1-800-252-7031

• The Commission has a 24-hour, toll free hotline to report suspected safety violations in the workplace: 1-800-452-9595

Written notice must be given to all employees within fifteen (15) days of the date Bonham ISD elects to cancel the workers’ compensation policy or if the insurance carrier intends to cancel the policy.

Notice to New Employees:

You have the right to choose not to be covered by the Bonham ISD workers’ compensation policy. You will have five (5) days from the date you begin employment to notify Bonham ISD in writing if you do not want to be covered by the employer’s policy.

If you have any questions concerning the workers’ compensation policy, contact Jana Garner, Executive Secretary to the Superintendent, at 903-583-5526 ext. 1100.

I, as a new employee of Bonham ISD, have reviewed the above notice.

Signature: ________________________________ Date: _____________________

Campus: _______________________________

BONHAM INDEPENDENT SCHOOL DISTRICT

Dear New Employee:

The USDE requires all state and local education institutions to collect information on ethnicity and race for students and staff. This information is used for state and federal accountability reporting, as well as for reporting to the Office of Civil Rights (OCR) AND THE Equal Employment Opportunity Commission (EEOC).

The federal government has developed a new standard for collecting and reporting this data in order to provide a more accurate picture of the nation's ethnic and racial diversity. These reporting categories were used in the 2000 Census.

The new standard enables individualsto be identified in both ethnic and racial classifications and in more than one racial category if applicable. In the past, individuals could only select one category.

Texas schools adopted the new standard in the 2009-2010 school year. As a result, you are being asked to complete the form attached to this letter.

Enclosed is the standard form required by the Texas Education Agency for collecting this information. Please complete the enclosed form and return it to Kelly Trampler along with the rest of your new employee packet.

Ifwe do not hear back from you, please be aware that the USDE requires the school district to employ observer identification as a last resort for federal reporting.

Dr. Marvin Beaty Superintendent of Schools

1005 Chestnut- P.O. Box 490 - Bonham, TX 75418 903-583-5526 - FAX 903-583-8463 -www.bonhamisd.org

It is the policy of Bonham Independent School District not to disaiminate on the basis of race, color, national origin, sex, or handicap in its vocational programs, services or activities as required by Title Vl of the Civil Rights Act of 1964, as amended: Title IX of the Educational Amendments of 1972; and Section 503 and 504 or the Rehabilitation Act of 1973; as amended. Bonham ISD will take steps to ensure that lack of English language skills will not be a barrier to admission an participation in all education programs and services.

Texas Education Agency Texas Public School Student/Staff Ethnicity and Race Data Questionnaire

The United States Department of Education (USDE) requires all state and local education institutions to collect data on ethnicity and race for students and staff. This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC).

School district staff and parents or guardians of students enrolling in school are requested to provide this information. If you decline to provide this information, please be aware that the USDE requires school districts to use observer identification as a last resort for collecting the data for federal reporting.

Please answer both parts of the following questions on the student’s or staff member’s ethnicity and race. United States Federal Register (71 FR 44866)

Part 1 Ethnicity: Is the person Hispanic/Latino? (Choose only one)

_____ Hispanic/Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

_____ Not Hispanic/Latino

Part 2 Race: What is the person’s race? (Choose one or more)

_____ American Indian or Alaska Native – A person having origins in any of the original peoples of North and South American (including Central America), and who maintains a tribal affiliation or community attachment.

_____ Asian – 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.

_____ Black or African American – A person having origins in any of the black racial groups of Africa.

_____ Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

_____ White – a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

___________________________________

Staff Name (please print)

___________________________________

Staff Signature

___________________________________

Staff Identification Number

___________________________________

Date

Texas Education Agency – March 2009

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 11/14/2016 N Page 1 of 3

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

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

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

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

- -

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):

1. A citizen of the United States

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

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

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

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)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 Today's Date (mm/dd/yyyy)

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

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

Employer Completes Next Page

Form I-9 11/14/2016 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1 Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

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

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Certification: I attest, under penalty of perjury, that (1) I have examined the document(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 (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative Today's Date(mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

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

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

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 (mm/dd/yyyy) Name of Employer or Authorized Representative

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

8. 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 Birth Abroad issued by the Department of State (Form FS-545)

3. Certification of Report of Birth issued by the Department of State (Form DS-1350)

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

5. Native American tribal document

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

Documents that Establish Employment Authorization

6. 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 11/14/2016 N

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.