PORT JERVIS PUBLIC SCHOOLS r ru en P.O. Box Port Jervis ... · Substitute Teachers form a valuable...

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PORT JERVIS PUBLIC SCHOOLS 9 Thompson Street

PO 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 LevelSubject Area

Second Choice LevelSubject Area

Third Choice LevelSubject Area

PERSONAL DATA

Dr Mr Mrs Ms

Last First Middle ADDRESS _________________ Telephone ( ) _____~

City State Zip Code

Social Security ______________ NYS Tchrs 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 amp Location of School Dates Attended Type of Diploma Earned High School

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

Name amp 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

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TEACHING EXPERIENCE

List most recent experience first Include any substitute teaching and indicate as such Dates Total Years Name amp Location of School Specific Nature of Position IfFull-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 amp Location of School Subject andor Grade Level

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

Language (s) other than English -------------------------------- shy

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

Hobbies Interests Other Abilities ------------------------------- shy

MILITARY SERVICE

Inclusive Dates Nature of AssignmentHighest Rank Attained Mo-Yr Mo-YrBranch 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)

CANDIDATES STATEMENT

Applications often fail to convey a candidates unique potential Please comment in your own handwriting in the space below why your particular abilitiesand 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

CANDIDATES 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

--

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 andor credits

( ) Indicates materials needed for your Substitute Teacher File

_middot__ Completed Application Form

__ Copy of College Degree or Degree Certification

Copy ofNew York State Education Teacher CertificationCopy on file middot

_ G~ - ~ jlLtLGUA ~t ica1iiU~-c

__ Completed Substitute Teacher Data Form

__ Documentation of Citizenship (See Enclosure)

__ Completed Federal and State tax forms

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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 middoteligible 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

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

university (non-certified) CATEGORYCshy 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 TEACHERHOME INSTRUCTOR UPDATE FORM

SCHOOL YEAR 2018 - 2019

SOC SECURITY NO-~-------shy

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

Grade Level Preferred (List 151 2d 3d choice)

Elementary (K-6) ____ Middle School (7-8) ___ High School (9-12) ___

Grade Levels Areas You Do Not Wish to Sub In

Have you ever been convicted of a felony crime YES NO ___

Ifyes Date ____ State --- shy

E-Mail Address ----------- shy

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 __

Applicants 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 DlTRICT 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 35 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)

1007

Lorelei Case Assistant Superintendent for Business

9 Thon1pson Street Port Jervis New York 12771

Phone (845) 858-3100 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

ID

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Name__________________

Position_________________

Building________

Person To Contact in an Emergency

Name__________________

Relationship________________

Home Phone ________

Work Phone_________

Cell Phone _________

OPTIONAL - Medical Details

Doctor__________________

Doctors 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

SCROD 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 ofrace

___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 NY 12771

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 Address _______________________________

TransitABA Number_---------------- shy(Must be 9 digits)

1 Account Number

Checking or Savings_-c--------------------------- shyPercent to be deposited (Ex 50) --------------------- shy

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 wwwirsgovFormW4

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

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

bull For 2018 you expect a refund of all federal income tax withheld because you expect to have no tax liability

If youre 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 arent 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 wwwirsgovW4App 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 youre having withheld compares to your projected total tax for 2018 If you use the calculator you dont 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 youre married and your spouse is also working read all of the instructions including the instructions for the Two-EarnersMultiple 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 1040shyES 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 wwwirsgov 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 wwwirsgovW4App to find out if you should adjust your withholding on Form W-4 or W-4P

Nonresident alien If youre 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 youre 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 dont 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 Wbull4 Department of the Treasury Internal Revenue service

Employees Withholding Allowance Certificate ~ Whether youre 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 ~18

0MB No 1545-0074

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 BOOM772M1213 for a replacement card ~ D 5 6 7

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

A d di ti on 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

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bull Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and 1

bull This year I expect a refund of all federal income tax withheld because I expect to have no tax liabilitzmiddotc______ic-----iJ 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

Employees signature (This form is not valid unless you sign it)~ Date~

8 Employers name and address (Employer Complete boxes 8 and 10 if sending to IRS and complete 9 First date of 10 Employer identification boxes 8 9 and 10 If sending to State Directory of New Hires) employment number (EIN)

For Privacy Act and Paperwork Reduction Act Notice see page 4 cat No 102200 Form W-4 (2018)

IT-2104

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 MarriedD Married but withhold at higher single rate D

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 NoD Are you a resident of Yonkers Yes D NoD

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

2 Total number of allowances for New York City (from line 29) 2

Use lines 3 4 and 5 below to have additional withholding per pay period under special agreement with your employer

3 New York State 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

IEmployees signature IDate

Penalty-A penalty 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 andor 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 Employers 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 employees 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 fife 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 $107650 or more during the tax year The total income of you and your spouse has increased to $107650 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 US Citizenship and Immigration Services

USCIS Form 1-9

0MB No 1615-0047 Expires 08312019

- 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

sectglitigpJLlfupf9yfi~1 tjfqr111iIJioij~ljcfAtt~st~tJ911 Efipaji~s mr1sLcompJetampbullalH~hHifirst~afofitifpioyn1il]t)~Wfsecttlii(qria6c_epJifJJaoh irfd ~- -shy - -Last Name (Family Name) First Name (Given Name) Middle Initial

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

niisgfi~e1uobull1 ~fFiiampi F~iJo 1afercshymiddotmiddot __ _ bull r

Other Last Names Used (if any)

State ZIP Code

Date of Birth (mmddyyyy) US Social Security Number

[I]J-[D-11111 Employees E-mail Address Employees Telephone Number

I am aware that federal law provides for imprisonment andor 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 NumberUSCIS Number)

D 4 An alien authorized to work until (expiration date if applicable mmddyyyy)

Some aliens may write NA 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 NumberUSCIS Number OR Form -94 Admission Number OR Foreign Passport Number

1 Alien Registration NumberUSCIS 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 Todays Date (mmlddyyyy)

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 ITodays Date (mmlddyyyy)

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 l142016 N

USCISEmployment Eligibility Verification Form I-9

Department of Homeland Security 0MB No 1615-0047 US Citizenship and Immigration Services Expires 08312019

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

Document Title Document Title Document Title ts f----------------11--------------shyIssuing Authority Issuing Authority Issuing Authority

Document Number Document Number Document Number

Expiration Date (if any)(mmlddlyWY) Expiration Date (if any)(mmlddywr)Expiration Date if any)(mmlddywr)

Document Title

f-----------------1~ Additional Information Issuing Authority

Document Number iif---------------l

Expiration Date if any)(mmlddlyyyy) -a=shy

Document Title

Issuing Authority ~i ~Ii

f---------------j) Document Number

Expiration Date (if any)(mmlddlyWY)

QR Code - Sections 2 amp 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 documents 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 employees first day of employment (mmlddYYW) (See instructions for exemptions)

Signature of Employer or Authorized Representative ITodays Date(mmlddlyyyy) ITitle of Employer or Authorized Representative

Last Name of Employer or Authorized Representative IFirst Name of Employer or Authorized Representative IEmployers Business or Organization Name

Employers Business or Organization Address (Street Number and Name) ICity or Town State ZIP Code 1

~N~~t11Wrfr1~f~tat1ihbull~n~Rll~1[e~~ci~rbel~(~iarfl[Mftfiiefl~maltgt~ftCr~~~~(it1t1pound~fl1lft[fi~lflif~ll Last Name (Family Name) First Name (Given Name) IMiddle Initial Date (mmlddlyyyy)

Cmiddot lf t_hE(~-~pl~YeEi1s _pr~v_iqjS -f1r8_1i( of~1TlplO~rnen1 a~~lotlZat_i_O_rj lei~_e~~ite9 middot _pf9~~_e ie___lh_f9r_[[i_at~Q-~ fQr ~t~_e_middotmiddot-~_o_S_~-rr~nt of-_r_ec~ip _~hattt~f_l_ish_~~---_ ~- middot _--_- continllfi]g_~_mp1~Yment8LJh6riZ8f-_o_r iq th_e s_pa_ce p~9victed_6el0~- -__ c- -middot -- 0)----=~--~- -middot ----middot _-middot _-_-middot) __ - ---__middot_middot imiddotmiddot--___i_-~- - tgtmiddoti middot -~ ___- ~------- shyDocument Title IDocument Number IExpiration Date (if any) (mmddyyyy)

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 documents1 the documents I have examined appear to be genuine and to relate to the individual

Signature of Employer or Authorized Representative Todays Date (mmddlyyyy) Name of Employer or Authorized Representative

Page 2 of3Fonnl-9 ll142016N

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 Documents that Establish Documents that Establish

Both Identity and Identity Employment Authorization Employment Authorization

bull AND

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

1 US Passport or US Passport Card Drivers 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 a Registration 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 issued information 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

issued by the Department of Statelfil 4_ Voters registration cardto work for a specific employer (Form DS-1350) because of his or her status

5 US Military card or draft record 4 Original or certified copy of birtha Foreign passport and

certificate issued by a State F 6 Military dependents ID card b Form 1-94 or Form l-94A that has county municipal authority orthe following 7 US 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 aliens 9 Drivers license issued by a Canadian nonimmigrant status as long as

6 US 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 bull

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 I 1142016 N Page 3 of3

PERSONAL DATA

Dr Mr Mrs Ms

Last First Middle ADDRESS _________________ Telephone ( ) _____~

City State Zip Code

Social Security ______________ NYS Tchrs 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 amp Location of School Dates Attended Type of Diploma Earned High School

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

Name amp 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

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TEACHING EXPERIENCE













MILITARY SERVICE



REFERENCES










Signature Date


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CELL PHONE ( ) ________


CERTIFICATION















Business Office



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







(Date) (Signature)

1007



Phone (845) 858-3100 Xl5531 Fax (845) 858-3187

OATH OF ALLEGIANCE





Date

712011

ICE

ID

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em-rBencY

Name__________________

Position_________________

Building________


Name__________________


Home Phone ________

Work Phone_________



Doctor__________________



Allergies_________________



SCROD DISTRICT

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











Position

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Bank Address _______________________________


1 Account Number


























0MB No 1545-0074









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IT-2104






























USCIS Form 1-9

0MB No 1615-0047 Expires 08312019








State ZIP Code















Country of Issuance












Document Title




Document Title















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Form 1-9 I 1142016 N Page 3 of3

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TEACHING EXPERIENCE













MILITARY SERVICE



REFERENCES










Signature Date


--


















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CELL PHONE ( ) ________


CERTIFICATION















Business Office



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







(Date) (Signature)

1007



Phone (845) 858-3100 Xl5531 Fax (845) 858-3187

OATH OF ALLEGIANCE





Date

712011

ICE

ID

-eabullbull

em-rBencY

Name__________________

Position_________________

Building________


Name__________________


Home Phone ________

Work Phone_________



Doctor__________________



Allergies_________________



SCROD DISTRICT

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











Position

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

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





Bank Address _______________________________


1 Account Number


























0MB No 1545-0074









$c-------~

--+------shy







IT-2104






























USCIS Form 1-9

0MB No 1615-0047 Expires 08312019








State ZIP Code















Country of Issuance












Document Title




Document Title




















bull AND























Form 1-9 I 1142016 N of3

REFERENCES










Signature Date


--


















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

---- ----

----------

--- ---





CELL PHONE ( ) ________


CERTIFICATION















Business Office



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







(Date) (Signature)

1007



Phone (845) 858-3100 Xl5531 Fax (845) 858-3187

OATH OF ALLEGIANCE





Date

712011

ICE

ID

-eabullbull

em-rBencY

Name__________________

Position_________________

Building________


Name__________________


Home Phone ________

Work Phone_________



Doctor__________________



Allergies_________________



SCROD DISTRICT

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











Position

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

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





Bank Address _______________________________


1 Account Number


























0MB No 1545-0074









$c-------~

--+------shy







IT-2104






























USCIS Form 1-9

0MB No 1615-0047 Expires 08312019








State ZIP Code















Country of Issuance












Document Title




Document Title




















bull AND























Form 1-9 I 1142016 N Page 3 of3

--


















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

---- ----

----------

--- ---





CELL PHONE ( ) ________


CERTIFICATION















Business Office



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







(Date) (Signature)

1007



Phone (845) 858-3100 Xl5531 Fax (845) 858-3187

OATH OF ALLEGIANCE





Date

712011

ICE

ID

-eabullbull

em-rBencY

Name__________________

Position_________________

Building________


Name__________________


Home Phone ________

Work Phone_________



Doctor__________________



Allergies_________________



SCROD DISTRICT

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











Position

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

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





Bank Address _______________________________


1 Account Number


























0MB No 1545-0074









$c-------~

--+------shy







IT-2104






























USCIS Form 1-9

0MB No 1615-0047 Expires 08312019








State ZIP Code















Country of Issuance












Document Title




Document Title




















bull AND























Form 1-9 I 1142016 N Page 3 of3

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

---- ----

----------

--- ---





CELL PHONE ( ) ________


CERTIFICATION















Business Office



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







(Date) (Signature)

1007



Phone (845) 858-3100 Xl5531 Fax (845) 858-3187

OATH OF ALLEGIANCE





Date

712011

ICE

ID

-eabullbull

em-rBencY

Name__________________

Position_________________

Building________


Name__________________


Home Phone ________

Work Phone_________



Doctor__________________



Allergies_________________



SCROD DISTRICT

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











Position

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

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





Bank Address _______________________________


1 Account Number


























0MB No 1545-0074









$c-------~

--+------shy







IT-2104






























USCIS Form 1-9

0MB No 1615-0047 Expires 08312019








State ZIP Code















Country of Issuance












Document Title




Document Title




















bull AND























Form 1-9 I 1142016 N Page 3 of3

Business Office



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







(Date) (Signature)

1007



Phone (845) 858-3100 Xl5531 Fax (845) 858-3187

OATH OF ALLEGIANCE





Date

712011

ICE

ID

-eabullbull

em-rBencY

Name__________________

Position_________________

Building________


Name__________________


Home Phone ________

Work Phone_________



Doctor__________________



Allergies_________________



SCROD DISTRICT

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











Position

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

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





Bank Address _______________________________


1 Account Number


























0MB No 1545-0074









$c-------~

--+------shy







IT-2104






























USCIS Form 1-9

0MB No 1615-0047 Expires 08312019








State ZIP Code















Country of Issuance












Document Title




Document Title




















bull AND























Form 1-9 I 1142016 N Page 3 of3



Phone (845) 858-3100 Xl5531 Fax (845) 858-3187

OATH OF ALLEGIANCE





Date

712011

ICE

ID

-eabullbull

em-rBencY

Name__________________

Position_________________

Building________


Name__________________


Home Phone ________

Work Phone_________



Doctor__________________



Allergies_________________



SCROD DISTRICT

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











Position

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

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





Bank Address _______________________________


1 Account Number


























0MB No 1545-0074









$c-------~

--+------shy







IT-2104






























USCIS Form 1-9

0MB No 1615-0047 Expires 08312019








State ZIP Code















Country of Issuance












Document Title




Document Title




















bull AND























Form 1-9 I 1142016 N Page 3 of3

ICE

ID

-eabullbull

em-rBencY

Name__________________

Position_________________

Building________


Name__________________


Home Phone ________

Work Phone_________



Doctor__________________



Allergies_________________



SCROD DISTRICT

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











Position

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

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





Bank Address _______________________________


1 Account Number


























0MB No 1545-0074









$c-------~

--+------shy







IT-2104






























USCIS Form 1-9

0MB No 1615-0047 Expires 08312019








State ZIP Code















Country of Issuance












Document Title




Document Title




















bull AND























Form 1-9 I 1142016 N Page 3 of3


SCROD DISTRICT

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











Position

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

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





Bank Address _______________________________


1 Account Number


























0MB No 1545-0074









$c-------~

--+------shy







IT-2104






























USCIS Form 1-9

0MB No 1615-0047 Expires 08312019








State ZIP Code















Country of Issuance












Document Title




Document Title




















bull AND























Form 1-9 I 1142016 N Page 3 of3

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

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





Bank Address _______________________________


1 Account Number


























0MB No 1545-0074









$c-------~

--+------shy







IT-2104






























USCIS Form 1-9

0MB No 1615-0047 Expires 08312019








State ZIP Code















Country of Issuance












Document Title




Document Title




















bull AND























Form 1-9 I 1142016 N Page 3 of3





















0MB No 1545-0074









$c-------~

--+------shy







IT-2104






























USCIS Form 1-9

0MB No 1615-0047 Expires 08312019








State ZIP Code















Country of Issuance












Document Title




Document Title




















bull AND























Form 1-9 I 1142016 N Page 3 of3

IT-2104






























USCIS Form 1-9

0MB No 1615-0047 Expires 08312019








State ZIP Code















Country of Issuance












Document Title




Document Title




















bull AND























Form 1-9 I 1142016 N Page 3 of3



USCIS Form 1-9

0MB No 1615-0047 Expires 08312019








State ZIP Code















Country of Issuance












Document Title




Document Title




















bull AND























Form 1-9 I 1142016 N Page 3 of3







Document Title




Document Title




















bull AND























Form 1-9 I 1142016 N Page 3 of3





bull AND























Form 1-9 I 1142016 N Page 3 of3

PORT JERVIS PUBLIC SCHOOLS r ru en P.O. Box Port Jervis ... · Substitute Teachers form a valuable...

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Transcript of PORT JERVIS PUBLIC SCHOOLS r ru en P.O. Box Port Jervis ... · Substitute Teachers form a valuable...