Temporary Employment Application · Employment Application for each vacancy. The application must...

Equal Employment Opportunity/Affirmative Action Employer

Date

Last Name First Name Middle Name Preferred Name

City State and Zip Code

Home Phone Other Phone

Temporary Employment Application

Address

Email Address

Personal InformationPosition Applied For

Are you entitled to work in the United States? Do you have a valid driver's license? If yes, list number and state

Are you related by blood or marriage to any person(s) employed by the University?

If yes, please list the name, relationship, and department.

Have you ever been convicted of a crime other than a minor traffic violation (includes DWI, misdemeanors, etc.)? If yes, list conviction and explain.

College/University City,State Degree Earned Date Earned

If subject to Military Selective Service registration, certify compliance by initialing. Initial here:______________

EducationHigh School City,State Highest Grade Completed Did you graduate?

Major Number of hours completed Type of Hours Did you graduate?

College/University City,State Degree Earned Date Earned

Major Number of hours completed Type of Hours Did you graduate?

Employment HistoryYou must complete this section. Do not mark "see resume". Include volunteer and military service, if applicable.

May we contact your present employer, if currently employed, regarding your work experience and qualifications?

Has disciplinary action ever been taken against you or have you ever been asked to resign from a job? If yes, explain.

Most Recent Position Employer Name and Address Dates Employed From: To:

Supervisor's Name Employer Contact Number Starting Salary Ending Salary

Are you still employed? Full-time position? Why did you leave or why do you wish to leave?

Describe your primary job duties.

Previous Position Employer Name and Address Dates Employed From: To:




Yes No Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No Yes No

Yes No Yes No

By signing below, I certify that I have read and agree with the above statements.

Applicant's Signature: Date:

Employment History (Continued)









AffirmationI attest that the information I have provided on my application materials (application, resume, etc.) is to the best of my knowledge and ability, up-to-date and accurate. I authorize institutions, employers, associations, registration and licensing boards and others to furnish whatever details are available concerning my qualifications. I authorize investigation by N.C. State University of all statements made by me and will not hold any parties disclosing information for this reason liable. I understand that false information or a failure to disclose relevant information may be grounds for termination, disciplinary and/or criminal action.

Additional InformationList any specialized skills or computer software knowledge you possess that are relevant to the position for which you are applying (Ex: MS Word, MS Excel, Dreamweaver, PageMaker, etc.).

List any licenses you possess or training programs you have attended recently that are relevant to the position for which you are applying.









Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

Equal Opportunity InformationVoluntary Demographic Data

Discrimination on the basis of race, sex, color, creed, religion, national origin, age, disability or veteran status is prohibited at NC State University. Sex or age or absence of a disability may be a bonafide occupational requirement in a small number of jobs. The information requested below will not affect your as an applicant. The information will be retained to ensure that the University's recruitment efforts are reaching all segments of the population.

NC State University regards discrimination on the basis of sexual orientation to be inconsistent with its goals of providing a welcoming work environment in which all of its students, faculty, and staff may learn and work up to their full potential. The University values the benefits of cultural diversity and pluralism in the academic community and welcomes men and women of good will without regard to sexual orientation.

Gender:

Ethnic Group:

Date of Birth: MM/DD/YYYY: __________________________

Male Do Not Wish To Disclose

White (Non-Hispanic) Black / African American (non-Hispanic) Hispanic / Latino Asian

Female

American Indian (including Alaskan Native

Hawaiian or Pacific Islander Do Not Wish To Disclose

Temporary Employment Information

Application Process

In order to be considered for temporary employment with NC State University you must complete a Temporary Employment Application for each vacancy. The application must be completed fully and submitted to the campus hiring department per instructions provided in the vacancy posting. Incomplete applications will not be processed. If you have questions about the application process, please contact the campus hiring department directly.

Please be sure to include your education, work experience, and job skills that are related to vacancy for which you are applying. This information will be used to determine if you meet the basic qualifications for the position and to evaluate your competitiveness versus other job applicants. The hiring department determines which candidates to interview and advises candidates of hiring decisions.

Proof of Employability

Federal law requires each new employee to complete the "Employee Information and Verification" section of the Federal Form I-9 and to submit certain original documents for examination in order to verify and certify identification and employment eligibility. This information must be provided to the hiring department on or before your third working day in the temporary position.

Pay

Temporary employees are paid on a bi-weekly basis with the option to receive pay by direct deposit to a financial institution of their choice or by actual paycheck. The University follows the provisions of the Fair Labor Standards Act for paying overtime as warranted to subject employees.

Appointment Length Restriction

The position for which you are applying is temporary and is based upon the needs of the hiring department. State policy restricts temporary employment to a maximum of 12 months. This applies to temporary employees working 20 hours or more per week on a recurring basis. Retirees and students as well as temporary employees who work only intermittently or who work fewer than 20 hours per week are not affected by the 12 month limit.

Computer Science Department Tracking Position # ____________ Application for Employment

Student ID#: ___________________________________ Semester: ______________ Yr:_________ First Name: _________________________ Middle Name: _________________________________ Last Name: ________________________________________ Name Suffix: __________________ Address (Local): __________________________________________________________________ City: ________________________________ State: ___________ Postal Zip: __________________ Local Phone: ________________________ Cell Phone: ___________________________________ Address (Permanent): ______________________________________________________________ City: _______________________________ State: ____________ Postal Zip: ________________ Permanent Phone: ___________________ Email Address: _________________________________ Have you ever been paid on the University Payroll? Yes ____ No ____ Are you currently on the University Payroll? Yes ____ No ____ If yes, which Department?:__________________________________ Hrs: ___________ per week YOUR SUPERVISOR MUST COMPLETE THIS SECTION BEFORE YOU TURN YOUR PAPERWORK INTO THE CSC ADMINISTRATIVE OFFICE (Third Floor EBII Room 3312) I have hired this temporary employee to be as a __________________________________for the ____Spring ____Summer I ___Summer II ___Fall, 20______ for Course # _______Section ______ Account Number: ______________________________ Pay Rate: __________________________ Employment Begins (mm/dd/yyyy): ________________________ Supervisor: ____________________________ _________________________________________ Print Name Signature Employee ID: ___________________ Employee Record #:______

Office Use Only Employee ID: _________________________ Record #:_________

Student Name: ___________________________________________________ Page 2

Gender: M or F Date of Birth: ___________________ U.S. Veteran: (Y/N) __________ Primary Ethnic Group: _____White ____African-American _______Am. Indian or Alaskan _____ Asian ____Hawaii/Pacific ____Hispanic __________ Other Class Status: _____________________ Disabled: (Y/N) ______ Disabled Veteran: (Y/N) _____ If disabled please explain: ________________________________________________________ Temp Category: Student, NC State ____ Student UNC System ____ Student, Other ____ Continuing Part-Time ____Intermittent _____ Retiree, NC State ____ Retiree, State of NC _____ Temporary ______ Citizenship Status: ___Native ___Naturalized ___ Alien Permanent __ Alien Temporary If Alien Permanent or Alien Temporary: Visa Country_______________ Visa/Permit Type: _____ Effective Date: _____________ Employment Eligibility Expiration Date: ____________________ (For F1 use dates on I-20, For J1 use the “J1 Student On-Campus Employment Authorization” form from OIS) Permanent residents and naturalized U.S citizens, enter your birth country: _______________________

Any NCSU employee to whom you are related and the relationship: ______________________________ Are you a student or have recently been a student (Y/N)?: _______ If yes continue this section: Major: ____________________________________ Status: __________ Overall GPA:_________ Circle courses successfully completed: E115, CSC114, CSC216, CSC210, CSC201, CSC246, CSC222, CSC302, CSC310, CSC333, MA241, ST371, ST372 Other CSC or MA:_______________ Work experience, languages, operating systems, etc._________________________________________ New: ____ Returning: ____ if yes, number of months experience: ________________________ As a temporary employee of the CSC department, I understand that I have been hired at will and I am subject to continuation or termination of employment at the discretion of the department. I understand for employment, I MUST SUBMIT A COPY OF MY SOCIAL SECURITY CARD. Signed________________________________________________________ Date___________________

V.12.06

NORTH CAROLINA STATE UNIVERSITY ACCEPTANCE OF TEMPORARY EMPLOYMENT TERMS

I am accepting a temporary position with North Carolina State University. I understand that the 12-month employment time limit for temporary employees does not apply to students or retirees who certify their status and agree to the following terms: (choose one status) Student Status _____ (Initials) I certify that I am enrolled in a post-secondary education institution. My student status is primary, and my working relationship is secondary to my role as a student. I understand that it is my responsibility to notify my supervisor if my status as a student changes. I am enrolled at:

_____ North Carolina State University. _____ a University within the UNC System. _____ another post-secondary institution.

Retiree Status _____ (Initials) I certify that I am a retiree receiving retirement income and/or social security benefits. I am not available for nor seeking permanent employment. I am a retiree of:

_____ North Carolina State University. _____ the State of NC. _____ Other.

Terms I understand that as a temporary employee, regardless of my length of service, I will not receive retirement credit, leave benefits, health insurance, or other state benefits. I also understand that if separated, I will not receive severance pay or priority re-employment consideration. I also understand that temporary employees are free at any time to seek employment that does provide benefits (with the State or otherwise). ________________________________ ___________________________________ Employee Signature Name (Print)

________________________________ ___________________________________ Department Date ________________________________ ___________________________________ Supervisor Signature Date

Rev: 10/06/2006 Version 1.2

NORTH CAROLINA STATE UNIVERSITY HUMAN RESOURCES

Selective Service Registration Certification for MaleTemporary and Graduate Student Workers

North Carolina law requires compliance with Selective Service registration as a condition of state employment. Almost all male U.S. Citizens and male immigrants residing in the United States and between the ages of 18 and 25 are required to be registered. Permanent resident aliens and seasonal agricultural workers (documented on Form I-688), refugees, parolees, asylees, and undocumented aliens are also required to be registered. Aliens in lawful non-immigrant status (H-1B, F, J, etc.) are not required to register while in this status. Compliance Certification: Please check the appropriate box(es). ___ I am registered with Selective Service.

___ I am not required to be registered with the Selective Service because:

___ I have not reached my 18th birthday ___ I am 26 years of age or older.

___ I am on active military duty. ___ I am attending a military service academy. ___ I am a student in a military officer procurement program. ___ I am a lawful non-immigrant on a visa. ___ I am a citizen of American Samoa and my permanent

residence is outside of the United States. Employee Type: ___ Temporary ___ Graduate Student Worker Name (print) _____________________________________________________ Hiring Department _____________________________ Dept. Phone #________ Signature ____________________________________ Date _______________

Hiring Department: Keep in employee’s file.

Employment Requirement All employees, including temporary/student employees, must sign up for Direct Deposit. If you do not sign up you will need to go to the payroll office in Administrative Building II on Sullivan Drive to pick up your check. They will assist you in signing up for direct deposit, so know or bring your bank account information. The preferred way to sign up is to go through the Administrative Portal from the NCSU webpage. http://www.ncsu.edu Click on FOR FACULTY & STAFF tab Under Campus Resources click on Administrative Portal Login using your unity id and password Click on the Employment Admin tab or HR tab Click on Employee Self Service Click on Direct Deposit Enroll/Update. If you have not received a paycheck in the past two months you will need to go to this site and re-activate the direct deposit.

This is your responsibility!!!!!

01/31/2007-DD Ver. 1

North Carolina State University – Bi-weekly Temporary Employee Time Record Name Work Period

Beginning PRID Time Sheet

Due Date SS# Work Period

Ending Box # Pay Day

ID# Dept: Empl # Invoice Contact:

Saturday Sunday Monday Tuesday Wednesday Thursday Friday

IN OUT IN OUT IN OUT IN OUT IN OUT IN OUT IN OUT

Daily Hrs: _____.__ ______.__ ______.__ ______.__ ______.__ _____.__ _____.__ Total hours worked for the week ending _________.___ Saturday Sunday Monday Tuesday Wednesday Thursday Friday

IN OUT IN OUT IN OUT IN OUT IN OUT IN OUT IN OUT

Daily Hrs: _____.__ ______.__ ______.__ ______.__ ______.__ _____.__ _____.__ Total hours worked for the week ending _________.___ Total Hours Worked: _________________

Department Code (Ouc)

Account Code (Fas)

Hourly Payrate

Project #

W/A Position #

Signatures Have you worked for any other University department or State government agency during this pay period? 9 yes 9 no If yes, indicate department/agency____________________________________________ I certify that all hours/flat rate amount have been recorded accurately. ___________________________________ Date: ____________ ________________________________________Date: ___________ Supervisor’s Signatures Employee’s Signature

Records must be maintained in the department for four years. Do not forward to Payroll. Reproduce as needed. Please make any necessary corrections or changes.

Special Notes 1. Paychecks may be picked up on payday between 7:30 a.m. to 5:00 p.m. 2. All partial hours worked must be rounded off to the closest 1/4 hour. For example: 8 hours 10 minutes = 8.25 not 8.1; similarly, 8 hours 5 minutes = 8.00 not 8.05. 3. Do not send your time-sheet by courier/campus mail. 4. Use black or blue ink to complete your time-sheet. Time-sheets completed by pencil are unacceptable. 5. Time-sheets must be signed by you and your supervisor. 8. Time-sheets with missing signatures will not be processed. You must submit original time-sheets as copies will not be accepted. 9. Any and all errors, scratchouts, etc. must be corrected and initialed by both you and your supervisor. For example: if you make two errors, both errors must be corrected and initialed by you and your supervisor.

Biweekly Payroll Helpful Tips Timesheet Rules • We would like everyone to use xtimesheet to prepare their timesheet. You can find out

about this application by going to http://courses.ncsu.edu/e115/common/admin/xtimesheet.html.

OR Fill out a timesheet manually (this is not advised) • Timesheets must be completed in ink • Timesheets must be filled out in increments of fifteen minutes • Minutes on timesheets must be converted into fractions

o Example: 15 min = .25 or ¼ 30 min = .50 or ½ 45 min = .75 or ¾

• All changes/corrections (including writing over a number) on timesheets must be initialed by the supervisor and employee

• PRID field to be entered 2R___ use your pay period schedule to find the 2-digit code which corresponds to the pay period you are submitting

• Employee and supervisor must sign and date timesheet in ink • DO NOT HOLD TIMESHEETS – PLEASE TURN THEM IN EACH PAY PERIOD!

When students hold their timesheets for several pay periods and turn them all in at once, they are taxed higher than if timesheets were turned in each pay period. University payroll uses an annualized tax calculation for each paycheck run.

• All time sheets turned in late must have a letter explaining why the time sheet is being turned in late. This letter must be in ink, dated and signed by both the employee and supervisor. Late time sheets will not be accepted without the late letter.

Temporary Employee Income Tax Withholding University Payroll would prefer that everyone (except nonimmigrant visa holders or "aliens") use the web-based NC-4 and W-4 system for entering tax withholding information If you do not change the tax withholding your taxes will be withheld at the single and 0 rate until you change it on-line.. All nonimmigrant visa holders must meet with the Nonresident Tax Specialist (Michelle Anderson, 515-4370) in the University Payroll Office to determine their tax status and complete the appropriate withholding forms. To submit allowances on-line go to the Employee Self Service page (please look below under Payment to see how to access) Payment All employees must sign up for Direct Deposit. To view your pay stub and to see other information pertaining to you as an employee: Go to http//www.ncsu.edu Click on FOR FACULTY & STAFF tab Under Campus Resources click on Administrative Portal Login using your unity id and password Click on the Employment Admin tab or My Employment Click on Employee Self Service

DIRECT DEPOSITEnrollment & Change Form

Biweekly Payroll Monthly Payroll

ENROLLME IN DIRECT DEPOSIT

CHANGEMY DIRECT DEPOSIT

CANCELMY DIRECT DEPOSIT*

* Monthly SPA and EPA faculty & staff are required to use direct deposit & may not cancel.

NAME(First, Middle, Last):

Campus E-mail Address:

Department:WorkPhone:

Soc Sec # (required by Federal Reserve) NCSU HR ID# (on your ID card above expire date)

Name of BANKor Financial Institution:

Deposit to my CHECKING or MONEY MARKET account (my name is on this account)

Deposit to my SAVINGS account (my name is on this account)

I am ATTACHING (check one & STAPLE HERE)

a PHOTOCOPY of a CHECK with my preprinted name & current address

a CHECK marked “VOID,” with my preprinted name & current address

an official BANK FORM, certified & stamped by a banking official, which provides my accountnumber and the bank routing number

a DEPOSIT SLIP for my savings account PLUS the bank routing number:

__________________________________

PLEASE NOTE: NCSU will transmit your payment electronically based on the informationyou have provided. If the transmission fails because you have given us incorrect or outdatedinformation, NCSU can only provide a replacement payment AFTER the University has received arefund from the financial institution. It is really important that you provide correct account & bankrouting numbers – and that you notify the NCSU Payroll Office immediately if you change banks oraccount numbers. NCSU has the right to retract & correct payments as necessary.

Note: The completed form must be received in the University Payroll Office, Campus Box 7233, Raleigh,NC 27695-7233 by 5:00PM on the 10th of the month in which it is to be effective.

I authorize my salary payment to be routed to the bank or financial institution listed on this form anddeposited into the account identified on the attached certification document. I understand and acceptthe conditions of participation in the direct deposit program.SIGNATURE: DATE:

INSTRUCTIONS

Anti-Discrimination Notice. It is illegal to discriminate against any individual (other than an alien not authorized to work in theU.S.) in hiring, discharging, or recruiting or referring for a fee because of that individual's national origin or citizenship status. It is illegal todiscriminate against work eligible individuals. Employers CANNOT specify which document(s) they will accept from an employee. Therefusal to hire an individual because of a future expiration date may also constitute illegal discrimination.

Section 1- Employee. All employees, citizens andnoncitizens, hired after November 6, 1986, must complete Section 1of this form at the time of hire, which is the actual beginning ofemployment. The employer is responsible for ensuring thatSection 1 is timely and properly completed.

examine any document that reflects that the employeeis authorized to work in the U.S. (see List A or C),

Preparer/Translator Certification. The Preparer/TranslatorCertification must be completed if Section 1 is prepared by a personother than the employee. A preparer/translator may be used onlywhen the employee is unable to complete Section 1 on his/her own.However, the employee must still sign Section 1 personally.

record the document title, document number andexpiration date (if any) in Block C, and

Photocopying and Retaining Form I-9. A blank I-9 may bereproduced, provided both sides are copied. The Instructions mustbe available to all employees completing this form. Employers mustretain completed I-9s for three (3) years after the date of hire or one(1) year after the date employment ends, whichever is later.Section 2 - Employer. For the purpose of completing thisFor more detailed information, you may refer to the Departmentof Homeland Security (DHS) Handbook for Employers, (FormM-274). You may obtain the handbook at your local U.S.Citizenship and Immigration Services (USCIS) office.Employers must complete Section 2 by examining evidence of

identity and employment eligibility within three (3) business days ofthe date employment begins. If employees are authorized to work,but are unable to present the required document(s) within threebusiness days, they must present a receipt for the application of thedocument(s) within three business days and the actual document(s)within ninety (90) days. However, if employers hire individuals for aduration of less than three business days, Section 2 must becompleted at the time employment begins. Employers must record:1) document title; 2) issuing authority; 3) document number, 4)expiration date, if any; and 5) the date employment begins.Employers must sign and date the certification. Employees mustpresent original documents. Employers may, but are not required to,photocopy the document(s) presented. These photocopies may onlybe used for the verification process and must be retained with the I-9.However, employers are still responsible for completing the I-9.

Privacy Act Notice. The authority for collecting thisinformation is the Immigration Reform and Control Act of 1986,Pub. L. 99-603 (8 USC 1324a).

This information is for employers to verify the eligibility of individualsfor employment to preclude the unlawful hiring, or recruiting orreferring for a fee, of aliens who are not authorized to work in theUnited States.This information will be used by employers as a record of their basisfor determining eligibility of an employee to work in the United States.The form will be kept by the employer and made available forinspection by officials of the U.S. Immigration and CustomsEnforcement, Department of Labor and Office of Special Counsel forImmigration Related Unfair Employment Practices.Submission of the information required in this form is voluntary.However, an individual may not begin employment unless this form iscompleted, since employers are subject to civil or criminal penalties ifthey do not comply with the Immigration Reform and Control Act of1986.

Section 3 - Updating and Reverification. Employersmust complete Section 3 when updating and/or reverifying the I-9.Employers must reverify employment eligibility of their employees onor before the expiration date recorded in Section 1. EmployersCANNOT specify which document(s) they will accept from anemployee.

Reporting Burden. We try to create forms and instructions that areaccurate, can be easily understood and which impose the leastpossible burden on you to provide us with information. Often this isdifficult because some immigration laws are very complex.Accordingly, the reporting burden for this collection of information iscomputed as follows: 1) learning about this form, 5 minutes; 2)completing the form, 5 minutes; and 3) assembling and filing(recordkeeping) the form, 5 minutes, for an average of 15 minutesper response. If you have comments regarding the accuracy of thisburden estimate, or suggestions for making this form simpler, youcan write to U.S. Citizenship and Immigration Services, RegulatoryManagement Division, 111 Massachuetts Avenue, N.W.,Washington, DC 20529. OMB No. 1615-0047.

If an employee's name has changed at the time this form isbeing updated/reverified, complete Block A.

If an employee is rehired within three (3) years of the datethis form was originally completed and the employee is stilleligible to be employed on the same basis as previouslyindicated on this form (updating), complete Block B and thesignature block.

PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM.

form, the term "employer" includes those recruiters and referrers fora fee who are agricultural associations, agricultural employers orfarm labor contractors.

Department of Homeland SecurityU.S. Citizenship and Immigration Services

Form I-9 (Rev. 05/31/05)YEMPLOYERS MUST RETAIN COMPLETED FORM I-9PLEASE DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS

OMB No. 1615-0047; Expires 03/31/07

Employment Eligibility Verification

If an employee is rehired within three (3) years of the datethis form was originally completed and the employee's workauthorization has expired or if a current employee's workauthorization is about to expire (reverification), completeBlock B and:

complete the signature block.

NOTE: This is the 1991 edition of the Form I-9 that has beenrebranded with a current printing date to reflect the recent transitionfrom the INS to DHS and its components.

A citizen or national of the United States

Please read instructions carefully before completing this form. The instructions must be available during completionof this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work eligible individuals. EmployersCANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because ofa future expiration date may also constitute illegal discrimination.Section 1. Employee Information and Verification. To be completed and signed by employee at the time employment begins.Print Name: Last First Middle Initial Maiden Name

Address (Street Name and Number) Apt. #

(month/day/year)

Date of Birth (month/day/year)

StateCity Zip Code Social Security #

CERTIFICATION - I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named

Address (Street Name and Number, City, State, Zip Code)

and that to the best of my knowledge the employee

I attest, under penalty of perjury, that I am (check one of the following):I am aware that federal law provides forimprisonment and/or fines for false statements oruse of false documents in connection with thecompletion of this form.

A Lawful Permanent Resident (Alien #) AAn alien authorized to work until

(Alien # or Admission #)

is eligible to work in the United States. (State employment agencies may omit the date the employee began

Employee's Signature Date (month/day/year)

Preparer and/or Translator Certification. (To be completed and signed if Section 1 is prepared by a personother than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the bestof my knowledge the information is true and correct.

Print NamePreparer's/Translator's Signature

Date (month/day/year)

Section 2. Employer Review and Verification. To be completed and signed by employer. Examine one document from List A ORexamine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number and expiration date, ifany, of the document(s).

ANDList B List CORList ADocument title:

Issuing authority:

Document #:

Expiration Date (if any):

Document #:

Print Name TitleSignature of Employer or Authorized Representative

Address (Street Name and Number, City, State, Zip Code) Date (month/day/year)Business or Organization Name

Section 3. Updating and Reverification. To be completed and signed by employer.B. Date of rehire (month/day/year) (if applicable)A. New Name (if applicable)

C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employmenteligibility.

Document #: Expiration Date (if any):Document Title:

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

Date (month/day/year)Signature of Employer or Authorized Representative

employee began employment on

employment.)

Expiration Date (if any):

employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the

Department of Homeland SecurityU.S. Citizenship and Immigration Services

Form I-9 (Rev. 05/31/05)Y Page 2

Employment Eligibility VerificationOMB No. 1615-0047; Expires 03/31/07

NOTE: This is the 1991 edition of the Form I-9 that has been rebranded with acurrent printing date to reflect the recent transition from the INS to DHS and itscomponents.

EPA SPASelect One!

TEMP

LISTS OF ACCEPTABLE DOCUMENTS

LIST A LIST B LIST C

Documents that Establish Documents that Establish

OR Identity AND

(Form N-560 or N-561)2. Certificate of U.S. Citizenship

Identity and EmploymentEligibility

7. Unexpired employment

1. Driver's license or ID card 1. U.S. social security card issued

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

1. U.S. Passport (unexpired or

I-688A)

issued by a state or outlyingpossession of the United Statesprovided it contains aphotograph or information such asname, date of birth, gender, height,eye color and address

by the Social SecurityAdministration (other than a cardstating it is not valid foremployment)

Card (Form I-688)

expired)

photograph

Document (Form I-571)

Employment Eligibility

(Form N-550 or N-570)

2. Certification of Birth Abroad3. Certificate of Naturalization 2. ID card issued by federal, state issued by the Department of State(Form FS-545 or Form DS-1350)or local government agencies or

entities, provided it contains aphotograph or information such asname, date of birth, gender, height,eye color and address

4. Unexpired foreign passport,with I-551 stamp or attachedForm I-94 indicating unexpiredemployment authorization

3. Original or certified copy of abirth certificate issued by a state,county, municipal authority oroutlying possession of the UnitedStates bearing an official seal

3. School ID card with a

5. Permanent Resident Card or Alien Registration Receipt Card with photograph (Form I-151 or I-551)

4. Voter's registration card

5. U.S. Military card or draft record

6. Military dependent's ID card 4. Native American tribal document6. Unexpired Temporary Resident

7. U.S. Coast Guard Merchant Mariner Card

5. U.S. Citizen ID Card (Form7. Unexpired Employment I-197)8. Native American tribal documentAuthorization Card (Form

6. ID Card for use of Resident8. Unexpired Reentry Permit Citizen in the United States

(Form I-179)are unable to present adocument listed above:

For persons under age 18 who

9. Unexpired Refugee Travel

authorization document issued byDHS (other than those listedunder List A)

10. School record or report card10. Unexpired EmploymentAuthorization Document issued byDHS that contains a photograph(Form I-688B)

11. Clinic, doctor or hospital record

12. Day-care or nursery schoolrecord

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

Documents that Establish Both

Form I-9 (Rev. 05/31/05)Y Page 3

(Form I-327)

Temporary Employment Application · Employment Application for each vacancy. The application must...

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Transcript of Temporary Employment Application · Employment Application for each vacancy. The application must...