alcorn state university office of human resources · confirmation of understanding and...

ALCORN STATE UNIVERSITY

Office of Human Resources

PERSONAL DATA

Printed Name: __________________________________________________ SS#: __________________________

(Name Must Be the Same As Shown On Social Security Card)

Mailing Address: ___________________________________________________________________________________________

____________________________________________________________________________________________(_________)___

City State County Zip Code

Home Phone: ( ) _______________________ Contact Phone: ( ) ____________________________

Date of Birth: ______________ Country of Birth: _________________ Sex: _____________ Marital Status: _____________

Ethnicity: Do you consider yourself to be Hispanic/Latino? ____ Yes (A person of Cuban, Mexican, Puerto Rican, South or Central

American, or other Spanish culture or origin, regardless of race.) ___No

Race: _____Black or African-American _____American Indian/Alaskan Native _____Asian _____White/Caucasian

______Native Hawaiian or Other Pacific Islander

Highest Educational Degree (check highest and list the year attained): ____Associate_________ _____Bachelor_________

____ED.__________ _____Master’s_________ ____Ph.D._________ _____ Some College_________

EMERGENCY CONTACT

Name: _________________________________________ Relationship _________________________

Address: __________________________________ City: ____________________ State: __________ Zip: _____________

Day Phone: _______________________ Evening Phone: _____________________ Cell Phone: ______________________

PREVIOUS EMPLOYMENT

Employer: ______________________________ Dates of Employment: __________________ to ________________

Address: _____________________________________________________________________________________________

City State Zip Code

Have you ever been employed by the State of Mississippi as a full-time employee? ____Yes ____No

If yes, what agency/department? _________________________________ Dates of Employment: _________________

CONFIRMATION OF UNDERSTANDING AND ACKNOWLEDGEMENT OF DRUG-FREE WORKPLACE POLICY

It is the policy of Alcorn State University to maintain a drug-free workplace, workforce and campus consistent with Federal laws as set

forth in the Drug-Free Workplace Act of 1988 and the Drug-Free Schools and Communities Act Amendments of 1989. Consequently,

all employees-faculty, staff (part-time or full-time) and students- are prohibited from the unlawful possession, manufacture, distribution,

dispensation, sale, use or in any way involve themselves with controlled substances and alcohol on university property or as part of any

university activity.

By signing below, I acknowledge that I have received a copy of the Drug-Free Workplace Policy, and I understand that as a condition

of my employment I must abide by the terms and provisions as set forth therein.

Employee Signature ________________________________________________ Date_______________________

Mississippi New Hire Reporting Form

Mail completed form to: Mississippi State Directory of New Hires P.O Box 312

Holbrook, MA 02343

Or fax completed form to: 1-800-937-8668

Effective October 1, 1997, all Mississippi employers (or independent contractors) are required to report certain information about personnel who have been newly hired, rehired, or have returned to work. Reports must be made within 15 calendar days from date of hire. Employers must either (1) complete this form, or (2) submit a copy of the worker’s IRS W-4 form with the “other information section” completed on this form, or (3) submit the information by magnetic tape or floppy diskette. To submit new hire reports electronically, call 1800-241-1330 to obtain information.

Below, please complete all employer information

EMPLOYER INFORMATION

*Federal Employer Identification Number (FEIN): - (Please the same FEIN for which listed employee(s) quarterly wages will be reported under)

State Employer Identification Number (SEIN): -

*Employer Name: _________________________________________ DBA: ___________________________

*Address: _________________________________________________________________________________

__________________________________________________________________________________________

(Please indicate the address where the Income Withholding Order will be sent)

*City: ___________________________ *State: _________ *Zip Code: ____________ +4: _________

Contact Name: _____________________________ Phone: ___________________________

Email: ____________________________________

Below, please complete one entry for each new employee

EMPLOYEE INFORMATION

*Social Security Number: - - Gender (circle one): Male Female

*First Name: ________________________________________ Middle: __________________________

*Last Name: ________________________________________

*Employee Address: ________________________________________________________________________

_________________________________________________________________________________________

*City: ___________________________ *State: _________ *Zip Code: ____________ +4: _________

Date of Birth: _____/_____/_______ Date of Hire: _____/_____/_______ State of Hire _______

Employee Salary: ____________________ Payment Frequency (circle one): Weekly Bi-weekly Monthly Annually

Is this employee eligible for medical insurance (circle one)? Yes No

For information please visit our website at www.ms-newhire.com or call us toll-free at 1-800-241-1330

http://www.ms-newhire.com/

New to the direct deposit programAdditions or Changes

See back of form for an explanation of some of the information asked for on this form. Stop all direct deposits effective

Telephone Number

Email Address

Fill in % or Dollar AmountPercent of Net Pay

Add CheckingChange Dollar AmountDelete Savings

City, State



City, State



City, State



City, State



City, State

PLEASE ATTACH A VOIDED CHECK OR A DOCUMENT PRE-PRINTED FROM YOUR FINANCIAL INSTITUTION VERIFYING THE INSTITUTION'SROUTING NUMBER AND YOUR ACCOUNT NUMBER FOR ACCURACY. STARTER CHECKS ARE PERMISSABLE. NO MORE THAN 5 ENTRIES PER EMPLOYEE.

A prenote may be required for new employees and for employees making changes to their direct deposit. A prenote sends your account type and numbers to the bank without any money to assure accuracy regarding account information entered in the system. If a prenote is applied, you will receive an actual check and the next check will be direct deposit.

Comments: Any time you change your direct deposit, you must make your changes very clear to the staff that will process the changes. Use this space, if necessary, to describe what you want to occur. This will help make your changes turn out the way you expect.

I authorize the Payroll Office to initiate electronic credit entries (direct deposits) for the amounts designated to the financial institution(s) indicated above. I further authorize, if necessary, debit entries and/or adjustments for any credit entries made in error to the accounts specified above. I understand that my direct deposit can be discontinued at any time due to infringement of University policy, procedure, or practice.

ALCORN STATE UNIVERSITYPAYROLL DIRECT DEPOSIT AUTHORIZATION

Employee Signature Date

5

Effective Date Financial Institution

Action Priority Account Type Routing Number Account Number

4



3




2




1

Employee Identification Employee Name (Last, First, Middle Initial) Department (Abbr. if necessary)

Boxes in the upper right-hand corner of the form: Check the applicable box. To delete all direct deposits, check the stop box thensign and date the form.

Employee Identification #: Although SSN numbers can be used here, we encourage use of your Alcorn ID number as an identifier.This action can aid in the protection of your identify. Your Alcorn ID number is located on the back of your ASU Gold Card.

Department, Work Phone, and Email Address: Please fill in the department in which you work, a reliable phone number, andemail address. This will help us contact you if we need additional information concerning your authorization or encounterproblems with your account(s).

Priority Number: Indicate which direct deposit account should receive funds first, second, third, etc. Note: All discriminate dollar amounts should come first and if all the remaining amount of money is going to the final account then 100% should be listed on the last priority. This means that 100% of the remaining balance goes to that final account.

Account Type: Check the appropriate account type for your institution(s). If you are unsure of the account type, please contactyour financial institution(s). Incorrect entries can delay receipt of funds up to five (5) business days.

Routing and Account Numbers: Generally, the routing number to your financial institutions is the nine (9) digit number located onthe bottom left-hand corner of your check followed by your account number. Some financial institutions may differ. Be careful not to include the check number which is located on the same line. If you are unsure of these numbers, please contact your financialinstitution(s) to confirm these numbers before submitting this form for processing. Incorrect entries can delay receipt of fundsup to five (5) business days.

Percent of Net Pay or Dollar Amount: Each direct deposit entry must have either a percent of net pay or dollar amount entered.

City, State: The city and state where the account was established.

Comments: While the comments section is optional, we encourage utilization of this section to ensure accuracy.

Employee Signature, Date: It is imperative that this form is dated and signed by the employee. Failure to do so will delay processing.

Please remit all direct deposit authorization forms to the Payroll Office for processing.

For additional questions or information regarding direct deposit, please contact the following:

601.877.3721Director of Payroll/Accountant Mrs. Tracey Wilson Mrs. Pamela D. Ratliff 601.877.3721

[email protected] [email protected] Assistant Coordinator of Payroll

Fax 601.877.4082

Note: If emailing, please indicate Direct Deposit on the subject line.

Notice: All data on this form is private, except for biographical information provided at the top of the form. The privatedata is not legally required; however, by not providing it, your direct deposit transaction will not be assured of going tothe correct financial institution, to the correct account or that the correct amount will be posted accurately. The privatedata listed on this form is available to representatives of your agency and employees of the State who perform personnelor payroll related functions, provided such individuals have a business reason to access the data. Others who may legally access this information are representatives of the Attorney General's Office, enforcement agencies with the statutory authority and persons/entities authorized by law or court order.

Payroll Direct Deposit Authorization Form Instructions

May 20111

Department of Human Resources

EMPLOYMENT “AT WILL”

Alcorn State University recognizes Employment At-Will. Employment At-Will is a

doctrine of American law that defines an employment relationship in which either party

can break the relationship with no liability, provided there was not express contract for a

definite term governing the employment relationship and that the employer does not

belong to a collective bargain (i.e., has not recognized a union). Under this legal

doctrine:

Any hiring is presumed to be “At-Will”; that is, the employer is free to discharge

individuals “for good cause, or bad cause, or no cause at all,” and the employee is

equally free to quit, strike, or otherwise cease work.

_______________________________________________________________ Signature Date

_______________________________________________________________ Social Security Number

DEPARTMENT OF HUMAN RESOURCES

Faculty/Staff Policy Acknowledgement Form

The Staff Policy Manual is located on our website at www.alcorn.edu. Click on the Discover

Alcorn tab, and scroll down to Administrative Offices; then, click on the Finance and

Administration link on the right side of the page, and select Policies and Procedures to view and

print the HR Staff Policy Manual. The Faculty Handbook can also be found on the university’s

website. On the Administrative Offices webpage, select the Academic Affairs link to retrieve the

Faculty Policies and Procedures Handbook. The human resources staff policy manual and the

faculty handbook are designed as general guides to provide information and understanding of

the policies and programs established by the institution. The guidebooks are also designed to

provide a document summary and procedure reference for current employees and those new

to Alcorn State University.

All employees are expected to familiarize themselves with the Staff Policy Manual and/or the

Faculty Policy Handbook (whichever is applicable).

I understand that Alcorn State University’s Faculty Policy Handbook and Staff Policy Manual are

not contracts of employment and should not be deemed as such.

Employee Signature

Employee Name (print)

Date

http://www.alcorn.edu/

Department of Human Resources www.alcorn.edu

CONFIDENTIALITY STATEMENT

I understand that because of my employment with Alcorn State University, I may/will be exposed to certain confidential information. “Confidential Information” means all data and information relating to the business and management of the Employer, including proprietary and trade secret technology and accounting records to which access is obtained by the Employee, including Work Product, Production Processes, Other Proprietary Data, Business Operations, Marketing and Development Operations, and Customers. Confidential Information will also include any information that has been disclosed by a third party to the Employer and governed by a non-disclosure agreement entered into between the third party and the Employer.

I understand that I am to hold/handle such information in strict confidence and not to disclose, discard, or distribute any information. I may only disclose confidential information if requested in writing to any authorized external legal entity.

Violations of confidentiality may be grounds for termination.

Last Name: _________________________ First Name: ______________________ Middle Initial: _____

Position: _____________________________________________________________________________

Address: _____________________________________________________________________________

City: ___________________________________ State: ______________________ Zip Code: _________

Telephone (H): ______________________________ Telephone (Cell): ___________________________

Email Address: ________________________________________________________________________

___________________________________ Date: _____/_____/_____ Employee Signature

___________________________________ Date: _____/_____/_____ Human Resources Representative

http://www.alcorn.edu/�

Human Resources ALCORN STATE UNIVERSITY

1 Policies & Procedures Manual Revised 4/2014

CONFLICTS OF INTEREST/OUTSIDE EMPLOYMENT POLICY ACKNOWLEDGMENT

Employee - Conflicts of Interest/Outside Employment Policy Acknowledgement Form

I have received a copy of the university's policy on conflicts of interest/outside employment. I have read and understand the policies on conflicts of interest/outside employment contained herein. I hereby declare that to the best of my knowledge I, nor any member of my immediate family, has any conflict between our personal affairs and the proper performance of my responsibilities for the organization that would constitute a violation of the university’s policies.

I also declare that I will continue to maintain my affairs in accordance with the university’s policy on conflicts of interest/outside employment.

Employee Signature Date

Employee Name (Print)

Department

Supervisor Signature

Please print and sign this form, and forward the original to the Department of Human Resources. A signed copy of this form shall be maintained in the employee’s personnel file.

REVISED VERSION 04162014

14.0 HUMAN RESOURCES POLICIES AND PROCEDURES

The organizational and governmental policies of Alcorn State University and the Board of Trustees of State Institutions of Higher Learning contained herein provide information to employees regarding certain employment-related rights and responsibilities. It is the responsibility of each employee to become familiar with the policies that govern the institution.

Any policy, procedure or statement which is found to be in conflict with the policies of the Board of Trustees of the State of Mississippi Institutions of Higher Learning, laws of the state of Mississippi, and federal laws and regulations is declared null and void.

14.1 PURPOSE

Policies contained herein are intended to provide employees with the information they need to maintain compliance with institutional, state and federal regulations. Policies should not be seen as a guarantee of continued employment or an assurance that a particular policy or procedure will be followed in every case or circumstance.

14.10 CONFLICTS OF INTEREST/ OUTSIDE EMPLOYMENT

It is the policy of Alcorn State University that its employees conduct the affairs of the University in accordance with the highest legal, ethical and moral standards. Conflicts of interest should be avoided where possible or otherwise disclosed and managed. Further, employees shall not use their University position to secure personal financial benefits for themselves or any member of their immediate family.

A conflict of interest arises whenever the employee has the opportunity to influence University operations or business decisions in ways that could result in a personal financial benefit to the employee or a member of an employee’s immediate family. Although certain specific examples of conflicts of interest are provided in this policy, they are meant only as illustrations, and supervisors and employees are expected to use good judgment to identify possible conflicts of interest and to manage such so as not to adversely influence Alcorn State University operations.

Nothing in this policy shall be construed to permit, even with disclosure, any activity that is prohibited by law. Violation of this policy may be grounds for immediate dismissal.

External activities can lead to conflicts of interest with regard to an employee’s University responsibilities. As such, this policy is intended to provide a framework for recognizing and managing employee conflicts of interest; and, whenever possible, for preventing even the appearance of conflicts of interest. While the primary goal of this policy is to prevent an employee’s external activities from adversely influencing Alcorn State University operations,

this policy is also intended to protect employees from undue suspicion that their external activities may improperly influence University operations.

Further, all employees must be available for and devote their full attention to their assigned duties and responsibilities during scheduled working hours. Additionally, employees having emergency response responsibilities must be reasonably available during non-scheduled hours. Each employee must ensure that his or her off-the-job activities do not adversely affect job performance with and are not contrary to the interests of the University.

The following guidelines and rules are established for all employees:

• All employees are required to complete and sign a Conflicts of Interest PolicyAcknowledgement form upon hire.

• Employment with the University will be the employee’s primary job responsibility andobligation; any other approved employment will be deemed secondary.

• The demands or requirements of outside or secondary employment may not beconsidered as excusable reasons for absences, tardiness, poor performance or other areasof concern from a personnel perspective.

• Prior to seeking or accepting outside employment, full-time employees must discuss asecondary job with the supervisor and/or department head to determine whether or notthe job is considered a “conflict of interest” as previously defined herein.

• Current employees considering outside employment must submit a request in writing forapproval to the supervisor and/or department head and complete the Conflicts of InterestDisclosure form prior to engaging in employment. Final approval of the President/IEOmust be obtained. The request must also be completed if an outside activity exists at thetime an employee is hired by the University.

• If the outside employment constitutes a conflict of interest, detracts from the employee’sresponsibilities, or has an appearance of a “conflict of interest,” the request will bedenied.

• If the President approves the outside employment, the Conflicts of Interest Disclosureform must be completed annually and placed on file in the Office of Human Resources.

• Unit heads shall carefully evaluate all circumstances relating to a potential conflict ofinterest before acting to approve or disapprove the associated activities. If the supervisoror department head approves the outside employment, the request shall be forwarded tothe President/IEO for final approval.

The following are examples of conflicts of interest requiring employee disclosure. Theseexamples are illustrations only and are not meant to be exclusive:

• Employee or immediate family member owns, in whole or in part, a business entitywith which the University does or proposes to do business, and the employee is in adecision-making role or otherwise is in a position to influence the University’sbusiness decisions regarding the business entity. The following are examples ofbusiness entities for which an employee disclosure is required:

Finance or accounting servicesAthletic equipment servicesConsultingCounselingCateringPC or other hardware servicesProgrammingArchitectural servicesLegal servicesGrant preparationTemporary personnel servicesOffice or lab suppliesPainting servicesLawn and grounds services

• Employee holds or assumes an executive, officer or director position in a for-profit ornot-for-profit business or entity engaged in commercial, educational, or researchactivities similar to those in which the University engages.

• Employee participants in consultation activities for a for-profit or not-for-profitbusiness or entity engaged in commercial, educational or research activities similar tothose of the University.

See also reference to the Mississippi Code Annotated, §25-4-105(1) and §25-4-105(3) (a) regarding conflicts of interest.

Alcorn employees desiring to engage in outside employment or practice of profession must complete this

form and forward it through the appropriate channels to the President for approval. APPROVAL IS REQUIRED ANNUALLY.

NAME

(Or Grant Name)

TITLE

Employment Activity is

Does the organization referenced above have a relationship with Alcorn State University YES NO

If yes, explain:

(Check one)

Yes No

that permission to engage in outside employment can be denied or canceled if the outside employment unduly interferes with my work

(1) (2)

Vice President of Unit

(3) (4)

(5)

Permission to Engage in Outside Employment (07/2017) AA/EOE/ADAI

The Board of Trustees of State Institutions of Higher Learning has established that "Institutional members of the faculty and staff are permitted to engage in

outside employment, provided permission is first obtained from the executive officer of the institution concerned, and provided further, that the executive officer

of the institution concerned shall grant permission to engage in outside employment only after having first determined that said outside employment will interfere

in no way with the institutional duties of the individual requesting such permission. In addition, such individual will not engage in a business or profession that

would in any manner compete with a similar business or profession over which he/she would have direct supervision, inspection, or purchasing authority within

the university or agency, such being a "conflict of interest." In particular, this directive is understood to cover (1) connection with any business enterprise as

consultant, owner, partner, officer, director, or agent; or (2) connection with any public office either by election, appointment, or employment.

APPLICATION FOR PERMISSION TO ENGAGE IN OUTSIDE EMPLOYMENT / AFFIRMATION OF NON-CONFLICT OF INTEREST

Alcorn State University

Director of Sponsored Programs

or that of Alcorn State University.

Signature of Employee

Human Resources Director

(If Employee is paid from Externally Funded Project)

President

Supervisor or Director of Unit

Date

If additional space required, please attach a separate sheet and indicate attachment by checking box:

I understand that I must take Personal Leave for any time I spend on outside employment during regular work hours. I also understand

APPROVALS:

Involve the use of Alcorn facilities and/or equipment?

Utilize Alcorn support personnel?

Interfere with normal Alcorn duties?

Utilize Alcorn supplies and commodities?

If yes to any of the above, please explain:

Name and address of organization for which work will be done (be specific):

Amount of time devoted to employment activity (explain):

Will this employment activity:

Check Yes or No

IMMEDIATE SUPERVISOR

Inside Alcorn State University Outside Alcorn State University

Explain nature of Employment Activity:

outside employment or practice of profession, if approved, will not constitute a conflict of interest with or detract from my responsibilities

permission to engage in outside employment or practice of profession at Alcorn State University. I further affirm that the requested

to the University.

In accordance with regulations established by the Board of Trustees of State Institutions of Higher Learning, I hereby request

DEPARTMENT

MISS. CODE ANN. § 25-1-113

EMPLOYEE CERTIFICATION AND AUTHORIZATION STATEMENT

NOTICE

Section 25-1-113, Mississippi Code of 1972, as amended, prohibits the hiring for public employment of individuals who have been convicted of or plead guilty to the unlawful taking or misappropriation of public funds effective July 1, 2013. Effective July 1, 2014, the State cannot continue to employ a person who has been convicted or pled guilty to the unlawful misappropriation of public funds. Specifically, Section 25-1-113, has been amended to read as follows:

The State and any county, municipality, or any other political subdivision may not employ or continue to employ a person who has been convicted or pled guilty in any court of this state, another state, or in federal court of any felony in which public funds were unlawfully taken, obtained or misappropriated in the abuse or misuse of the person’s office or employment or money coming into the person’s hands by virtue of the person’s office or employment.

EMPLOYEE CERTIFICATION AND AUTHORIZATION

I have been notified that as an employee of the State of Mississippi I cannot have been convicted of or pled guilty in any court of this state, another state, or in federal court of any felony in which public funds were unlawfully taken, obtained or misappropriated in the abuse or misuse of my office or employment or money coming into my hands by virtue of my office or employment. I understand that any conviction of embezzlement will disqualify me from employment with the State of Mississippi and result in my termination.

I swear or affirm that I have never been convicted or pled guilty in any court of this state, another state, or in federal court of any felony in which public funds were unlawfully taken, obtained or misappropriated by the abuse or misuse of any office or employment or money coming into my hands by virtue of my office or employment.

I hereby authorize Alcorn State University to conduct a background check of my criminal history at any time as a condition of and/or subsequent to my employment. I understand and acknowledge that I may revoke my permission for such background check. In such case, no background check investigation will be done and my employment may be terminated. I further understand and acknowledge that should the criminal background check occur and it establishes that I have been convicted or plead guilty to misuse of public funds in violation of Section 25-1-113 my employment will terminate and I will have no recourse against Alcorn State University or the Board of Trustees of State Institutions of Higher Learning.

Signature of Employee Date

Employee's Name – Printed Date of Birth

Social Security Number

Department

Signature of Witness Date

Name of Witness - Print

Memorandum of Understanding

Between

ALCORN STATE UNIVERSITY

Alcorn State, Mississippi 39096-7500

And

ASU Employees

Overtime/ Compensatory Time Agreement for Salaried Non-Exempt Employees

Background/Policy:

It is the policy of Alcorn State University that all faculty, executive, highly-compensated

administrators and certain other professional staff are exempt from the provisions of the FLSA

(Fair Labor Standards Act).

Salaried nonexempt (earning more than $23,660 annually) employees will receive

compensatory time (time in lieu of pay) for work in excess of 40 physical hours per week.

Executive, Administrative, and Professional exempt employees shall not be awarded

compensatory time. Compensatory time is given at the rate of 1.5 times for all hours

worked during the week in which the overtime occurs. Overtime hours for emergency personnel

(fire and police departments) will be based upon a work period of 28 days and will be calculated after

212 hours are accumulated in each work period. After an employee has accumulated a maximum of

240 hours (480 hours for police officers, firefighters, computer, and outside sales), the

employee shall be paid overtime for hours worked above the 240 (or 480) hours at 1.5 times the

number of hours worked. In instances where there are less than five (5) emergency personnel

assigned to work in the Emergency Management Department, all overtime hours will be paid at the

employee’s regular rate of pay for each hour worked beyond the 212 hours in a 28 day work period.

Employees required to be on duty at the worksite for 24 hours or more shall not be compensated for

eight (8) hours per day for sleep time and one (1) hour per day for meal periods. If conditions are such

that the employee is not allowed at least five (5) hours of sleep during the sleep-and eat period, or if the

employee ends up working during that period, the hours revert to compensable time.

Supervisors are encouraged to permit the use of compensatory time within a reasonable period of time

from when the time was accrued unless doing so would “unduly disrupt” the workplace.

Purpose:

The purpose of this MOU is to establish an understanding and agreement that compensatory time

will be granted in lieu of monetary compensation prior to the performance of any and all overtime

work according to the above policy.

Terms and Conditions:

It is agreed that an employee who has accrued Compensatory Leave and requests use of the time

be permitted to use the time off within a reasonable period after making the request if it does not

unduly disrupt the operations of the department/university. Compensatory Leave must be earned

before it can be used and must be used prior to the use of accrued Personal Leave.

Memorandum of Understanding

Compensatory Time/ Overtime Agreement

(This portion to be maintained in the HR file)

Purpose:

The purpose of this MOU is to establish an understanding and agreement that

compensatory time will be granted in lieu of monetary compensation prior to the

performance of any and all overtime work according to the above policy.

Terms and Conditions:

It is agreed that an employee who has accrued Compensatory Leave and requests use of

the time be permitted to use the time off within a reasonable period after making the

request if it does not unduly disrupt the operations of the department/university.

Compensatory Leave must be earned before it can be used and must be used prior to the

use of accrued Personal Leave.

My signature below denotes that the information contained in this memorandum has been

discussed with me by my supervisor and/or Human Resources. I do hereby understand

and agree to the terms and conditions as stated within.

______________________________

(Employee’s Signature)

______________________________

(Print Name)

______________________________

(ASU ID #)

______________________________

(Department)

______________________________

Human Resources Representative

______________________________

(Date)

Alcorn State University is committed to equal employment opportunity and affirmative action

for Vietnam Era and Special Disabled Veterans. As a government contractor, Alcorn State

University is subject to Sections 503 and 504 of the Rehabilitation Act of 1973, The Americans

with Disabilities Act of 1990 (ADA), and therefore must comply with governmental record

keeping, reporting , and other requirements.

A “Veteran of the Vietnam era” is defined as (1) an individual who served more than 180 days of

active military, naval, or air services, any part of which was during the period August 5, 1964

through May 7, 1975, and was honorably discharged or released; or (2) was discharged or

released because of a service-connected disability.

A “Special Disabled Veteran” is defined as (1) an individual who is entitled to compensation

(including those receiving military retirement pay but who would otherwise be entitled to

compensation”|) under laws administered by the Veterans administration for disability rated at 30

percent or more or rated at 10 or 20 percent in the case of those determined to have serious

employment disability: or (2) an individual discharged or released from active duty because of

service-connected disability.

Veterans, as defined above, are asked to identify themselves by providing the requested

information. All information will be considered confidential and will be used only in accordance

with meeting the requirements and obligations of the Acts previously mentioned. Choosing not

to provide this information will not result in adverse treatment or disciplinary action.

DATE: _______________________________________________________________________

NAME: ______________________________________________________________________

SOCIAL SECURITY NUMBER: __________________________________________________

POSITION TITLE: _____________________________________________________________

DEPARTMENT/OFFICE: _______________________________________________________

VETERAN’S STATUS

__________ VIETNAM ERA ___________ DISABLED VETERAN

Revised June 2016

__________________________ __________________

Voluntary Self-Identification of Disability

Form CC-305 OMB Control Number 1250-0005

Expires 1/31/2017 Page 1 of 2

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to

qualified people with disabilities i To help us measure how well we are doing, we are asking you to tell us if you

have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will

choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used

against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may

become disabled at any time, we are required to ask all of our employees to update their information every five

years. You may voluntarily self-identify as having a disability on this form without fear of any punishment

because you did not identify as having a disability earlier.

.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that

substantially limits a major life activity, or if you have a history or record of such an impairment or medical

condition.

Disabilities include, but are not limited to:

Blindness

Deafness Cancer Diabetes

Epilepsy

Autism

Cerebral palsy

HIV/AIDS

Schizophrenia

Muscular dystrophy

Bipolar disorder

Major depression

Multiple sclerosis (MS)

Missing limbs or partially missing limbs

Post-traumatic stress disorder (PTSD) Obsessive compulsive disorder Impairments requiring the use of a wheelchair

Intellectual disability (previously called mental retardation)

Please check one of the boxes below:

☐ YES, I HAVE A DISABILITY (or previously had a disability)

☐ NO, I DON’T HAVE A DISABILITY

☐ I DON’T WISH TO ANSWER

Your Name Today’s Date

i

Voluntary Self-Identification of Disability

Form CC-305 OMB Control Number 1250-0005

Expires 1/31/2017 Page 2 of 2

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities.

Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples

of reasonable accommodation include making a change to the application process or work procedures,

providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal

employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract

Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required

to respond to a collection of information unless such collection displays a valid OMB control number. This

survey should take about 5 minutes to complete.

www.dol.gov/ofccp

Public Employees’ Retirement System of Mississippi 429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.5261, fax www.pers.state.ms.us

Reemployment of PERS Service Retiree Certification/Acknowledgement Form 4B – Revised 3/9/2012 Please print or type in black ink. A Form 4B, Reemployment of PERS Service Retiree Certification/Acknowledgement, should be submitted each fiscal year (July 1 – June 30) of reemployment. See www.pers.state.ms.us/pdf/regulations/Reg34.pdf for rules governing reemployment. Completed form should be mailed or faxed to PERS. See bottom of form for contact information.

Retiree Information

First Name: _____________________________________ MI: _________ Last Name: ______________________________________________________

Mailing Address: ________________________________________________ City: ___________________________ State: _______ Zip: _____________

Social Security No.: _______________________________E-Mail: _______________________________________________________________________

Phone: ________________________________ Cellular Home Work Phone: _______________________________ Cellular Home Work

Position/Agency from which Retired: _______________________________________________ Retirement Date mm/dd/ccyy: ______________________

Annual Retiree Acknowledgement and Election – Please check one.

I hereby acknowledge that I have read, understand, and agree to comply with the provisions for reemployment as outlined in PERS Board Regulation 34, Reemployment after Retirement, which stipulates that I must be retired at least 90 days or I forfeit my retirement benefit. With that understanding, I make the following annual election in accordance with Miss. Code Ann. §25-11-127 (1972, as amended):

A. ____ I hereby elect to be employed by a covered employer for a period of time not to exceed one-half of the normal working days or hours for the full-time equivalent position during the state fiscal year indicated in Section 3, and I will receive no more than one-half of the salary in effect for the position at the time of employment. The normal working days or hours for the full–time equivalent position are ______ days or ______ hours and I will work no more than _______ days or ______ hours during the state fiscal year indicated in Section 3. The full-time annual salary authorized for this position is $____________________ and I will earn no more than $____________________ during the state fiscal year indicated in Section 3.

B. ____ I hereby elect to earn an annual salary that will not exceed 25 percent of the final average compensation used in calculating my service retirement allowance. My final average compensation at retirement was $____________________ and I will earn no more than $_____________________ from all PERS-covered employers during the state fiscal year indicated below.

If an authorized representative signs this form, attach a copy of the durable power of attorney, conservatorship or guardianship papers, or other legal documents as proof of authority to sign this form.

Retiree’s Signature: _______________________________________________________________________ Date mm/dd/ccyy:______________________

Employer Certification – This section should be completed by an authorized employer representative, not the retiree.

I hereby certify that the above-named individual, who is a service retiree receiving benefits from PERS, is employed in the below-named position in accordance with the reemployment provisions as authorized in Miss Code Ann. §25-11-127 (1972 as amended) and in accordance with the provisions of PERS Regulation 34, Reemployment after Retirement. I understand that wages earned and paid to the above-named individual during this period of employment will be reported in accordance with reporting requirements prescribed by PERS and the applicable employer contributions on the wages actually paid must be submitted. I further understand that any person who makes a false statement or shall falsify or permit to be falsified any record of a retirement plan administered by PERS in an attempt to defraud the plan may be subject to criminal prosecution, and with that understanding, I certify that the below information is true and correct.

Retiree’s Position Held/Job Title: _____________________________________________ Fiscal Year of Reemployment (July 1 - June 30): ________

Retiree’s Hire Date mm/dd/ccyy: ___________________________________Termination Date mm/dd/ccyy: ____________________________________

Employer Name: ____________________________________________________________ Employer No.: _____________________________________

Employer Representative’s Name: ________________________________ Employer Representative’s Title: _____________________________________

Employer Representative’s Phone: _________________________ Fax: _________________________ E-Mail: __________________________________

Employer Representative’s Signature: _________________________________________________________ Date mm/dd/ccyy: _____________________

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 89-350-12-8-1-000 (Rev. 11/12)

MISSISSIPPI EMPLOYEE'S WITHHOLDING EXEMPTION CERTIFICATE

Employee's Name SSN

Employee's ResidenceAddress

Marital Status

EMPLOYEE: 1. Single

File this form with your employer. Otherwise, you must withhold Mississippi income tax from the full amount of your wages.

EMPLOYER:Keep this certificate with your records. If the employee is believed to have claimed excess exemption, the Department of Revenue should be advised.

Personal Exemption Allowed

CLAIM YOUR WITHHOLDING PERSONAL EXEMPTIONAmount Claimed

Enter $6,000 as exemption . . . . $

Mississippi Department of RevenueP.O. Box 960

Jackson, MS 39205Number and Street City or Town State Zip Code

(Check One)

(a)

(b)

Spouse NOT employed: Enter $12,000 $

Spouse IS employed: Enter that part of $12,000 claimed by you in multiples of $500. See instructions 2(b) below . $

2. Marital Status

3. Head of Family

Enter $9,500 as exemption. To qualify as head of family, you must be singleand have a dependent living in the home with you. See instructions 2(c)and 2(d)below . . . . . . . . . . . . $

You may claim $1,500 for each dependent*, other than for taxpayer and spouse, who receives chief support from you and who qualifies as a dependent for Federal income tax purposes.* A head of family may claim $1,500 for eachdependents excluding the one which qualifies youas head of family. Multiply number of dependentsclaimed by you by $1,500. Enter amount claimed . . .

4. Dependents

Number Claimed

$

5. Age and Blindness

● Age 65 or older Husband Wife Single

● Blind Husband Wife Single

Multiply the number of blocks checked by $1,500. Enter the amount claimed . . . . .* Note: No exemption allowed for age or blindness

for dependents.

$

$

1. The personal exemptions allowed: (a) Single Individuals $6,000 (d) Dependents $1,500 (b) Married Individuals (Jointly) $12,000 (e) Age 65 and Over $1,500 (c) Head of family $9,500 (f) Blindness $1,500

2. Claiming personal exemptions: (a) Single Individuals enter $6,000 on Line 1.

Military Spouses Residency Relief Act Exemption from Mississippi Withholding

INSTRUCTIONS

6. TOTAL AMOUNT OF EXEMPTION CLAIMED - Lines 1 through 5...

* Note: No exemption allowed for age or blindness for dependents.

$

7. Additional dollar amount of withholding per pay period if agreed to by your employer . . . . . . . . . . . . . . . . . $

8. If you meet the conditions set forth under the Service Member Civil Relief, as amended by the Military Spouses Residency Relief Act, and have no Mississippi tax liability, write "Exempt" on Line 8. You must attach a copy of the FederalForm DD-2058 and a copy of your Military Spouse ID Card tothis form so your employer can validate the exemption claim..

I declare under the penalties imposed for filing false reports that the amount of exemption claimed on thiscertificate does not exceed the amount to which I am entitled or I am entitled to claim exempt status.

Employee's Signature: Date:

(e) An additional exemption of $1,500 may be claimed by either taxpayer or spouse or both if either or both have reached the age of 65 before the close of the taxable year. No additional exemption is authorized for dependents by reason of age. Check applicable blocks on Line 5.

(d) An additional exemption of $1,500 may generally be claimed for each dependent of the taxpayer. A dependent is any relative who receives chief support from the taxpayer and who qualifies as a dependent for Federal income tax purposes. Head of family individuals may claim an additional exemption for each dependent excluding the one which is required for head of family status. For example, a head of family taxpayer has 2 dependent children and his dependent mother living with him. The taxpayer may claim 2 additional exemptions. Married or single individuals may claim an additional exemption for each dependent, but

(c) Head of FamilyA head of family is a single individual who maintains a home which is the principal place ofabode for himself and at least one other dependent. Single individuals qualifying as a head of family enter $9,500 on Line 3. If the taxpayer has more than one dependent, additional exemptions are applicable. See item (d).

(b) Married individuals are allowed a joint exemption of $12,000.If the spouse is not employed, enter $12,000 on Line 2(a). If the spouse is employed, the exemption of $12,000 may be divided between taxpayer and spouse in any manner they choose - in multiples of $500. For example, the taxpayer may claim $6,500 and the spouse claims $5,500; or the taxpayer may claim $8,000 and the spouse claims $4,000. The total claimed by the taxpayer and spouse may not exceed $12,000. Enter amount claimed by you on Line 2(b).

(f) An additional exemption of $1,500 may be claimed by either taxpayer or spouse or both if either or both are blind. No additional exemption is authorized for dependents by reason of blindness. Check applicable blocks on Line 5. Multiply number of blocks checked on Line 5 by $1,500 and enter amount of exemption claimed.

should not include themselves or their spouse. Married taxpayers may divide the number of their dependents between them in any manner they choose; for example, a married couple has 3 children who qualify as dependents. The taxpayer may claim 2 dependents and the spouse 1; or the taxpayer may claim 3 dependents and the spouse none. Enter the amount of dependent exemption on Line 4.

3. Total Exemption Claimed:Add the amount of exemptions claimed in each category and enter the total on Line 6. This amount will be used as a basis for withholding income tax under the appropriate withholding tables.

4. A NEW EXEMPTION CERTIFICATE MUST BE FILED WITH YOUR EMPLOYER WITHIN 30 DAYS AFTER ANY CHANGE IN YOUR EXEMPTION STATUS.

5. PENALTIES ARE IMPOSED FOR WILLFULLY SUPPLYING FALSE INFORMATION

6. IF THE EMPLOYEE FAILS TO FILE AN EXEMPTION CERTIFICATE WITH HIS EMPLOYER, INCOME TAX MUST BE WITHHELD BY THE EMPLOYER ON TOTAL WAGES WITHOUT THE BENEFIT OF EXEMPTION..

7. To comply with the Military Spouse Residency Relief Act (PL111-97) signed on November 11, 2009.

q p p p ymay claim an additional exemption for each dependent excluding the one which is required for head of family status. For example, a head of family taxpayer has 2 dependent children and his dependent mother living with him. The taxpayer may claim 2 additional exemptions. Married or single individuals may claim an additional exemption for each dependent, but

EMPLOYER, INCOME TAX MUST BE WITHHELD BY THE EMPLOYER ON TOTAL WAGES WITHOUT THE BENEFIT OF EXEMPTION..

7. To comply with the Military Spouse Residency Relief Act (PL111-97) signed on November 11, 2009.

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