faculty credentials/intent to hire form...faculty credentials/intent to hire form (all original...

Faculty Credentials/Intent to Hire Form

(ALL original forms must be returned to the Human Resources Office for processing with required documentation attached. Incomplete packets will NOT be processed.)

Directions: Supervisor’s should complete this form and bring the applicant to the Human Resources Office on the Birmingham Campus, Administration Building A (Room 103) or the Bessemer campus, Administration Building A (Room 101) to begin the official application process.

Prospective Employee: ______________________________________________ _____________________________________________ First Name Last Name

Maiden Name: ___________________________________________ Other Names Used: _____________________________________

Address: _________________________________________________________ _____________________________ ____________ _________ City State Zip Code

Social Security Number: ________________________________ Email Address:___________________________________________ Department: ___________________________________________________________________________________________________________ Course(s) Eligible to Teach: __________________________________________________________________________________________ _________________________________________________________________________________________ Direct Supervisor: ____________________________________________________________________________________________________ Part I: EDUCATION QUALIFICATION

List, from highest degree, certificate or diploma earned to lowest, all colleges/ universities you have attended or transferred from in order to complete the degree, certificate or diploma. DO NOT LIST degrees, certificates or diplomas that are unrelated to the position you are seeking. Also, DO NOT list degrees you are currently working towards but have not earned.

_______________________________________________________________ ___________ __________________________ ___________ Name of College/University Degree/ Certif. Major (must be accurate) Year Earned Diploma Earned



Part II: ADDITIONAL CREDIT HOURS (no degree earned):


Part III: TRANSCRIPTS REQUEST:

ATTACH COPIES OF YOUR UNOFFICIAL TRANSCRIPTS TO THIS FORM. Failure to attach unofficial transcripts will delay the application process.

PAGE 1 of 2—Faculty Credentials/Intent to Hire Form

Part IV: LICENSES AND CERTIFICATIONS REQUEST:

PLEASE ATTACH COPIES OF LICENSE(S) AND CERTIFICATION(S) TO THIS FORM.

License/ Certification Type: ______________________________ Discipline/Field: _____________________________________ License # (if applicable): ___________________________________ Expiration Date: _____________________________________ Part V: ELIGIBILITY TEST (check all that apply):

____ The applicant has a ____Doctorate degree ____ Specialist degree ____ Masters degree ____ Bachelors Degree____Certification ____ Diploma ____Work experience in the exact field in which he/she is requesting to teach. (Work experience requires a Letter(s) from previous employer(s) where experience was obtained)

____ The applicant has 18 graduate hours in the exact field in which he/she is requesting to teach. The 18 graduate hours must appear on your transcript in the field of study in which you have applied.

How many years of field experience does the applicant have if applying for a Career Technical teaching position?____

My signature below verifies, I understand ALL official transcripts must be submitted (unopened) or mailed to Mrs. Janice McGee, the Director of Human Resources within 14-business days (from hire date). My failure to comply with this requirement renders my contract null/void. I also understand my employment is contingent upon receiving a clear background check. Applicant Signature _______________________________________________ Date: ________________________________________

The applicant credentials _______ meets _______ does not meet the requirement(s) to teach in the above position(s). His/Her employment is expected to begin on ____________________________, ____________, 20________. My signature below indicates the above applicant is approved and meets the requirements for new hire processing. Supervisor_____________________________________________________________ Date: ____________________________________

PAGE 2 OF 2— Faculty Credentials/Intent to Hire Form

INTERNAL OFFICE USE ONLY

Approved: ________________________________________________________________ Date: _____________________________ Department Chair Approved: ________________________________________________________________ Date: _____________________________ Associate Dean Approved: ________________________________________________________________ Date: _____________________________ Academic Dean/Career Technical Dean

_____ Qualified _____ Not Qualified _____ Incomplete Packet Approved: ______________________________________________________________, Vice President of Instruction

REQUEST, AUTHORIZATION, CONSENT, AND RELEASE

FOR BACKGROUND INFORMATION

I have been informed and acknowledged that on December 13, 2007 the State Board of Education adopted Policy 623.01 requiring criminal background checks for all new and current employees. I understand that I may voluntarily consent to the use of my social security account number for the purpose of conducting a criminal background check. I further understand that my voluntary consent to use my social security account number is being requested for purposes of conducting a criminal background check, pursuant to the authority of the State School Board Policy 623.01. The information I have given in my employment application, interviews, and/or related resumes and documents is true, complete, and accurate. I understand and agree that if employed, and/or during any period of employment, any false statements, misrepresentations of facts, or omission made by myself become known, my employment shall be subject to immediate termination. I understand that in the event a conviction for a felony or any crime involving moral turpitude is found that the procedures set out in the guidelines for State Board Policy 623.01 will be followed. I have read and completely understand this release.

(PLEASE PRINT) Name: _____________________________________________________________________________________________________ Address: _____________________________________________________________________________________________________ _________________________________________________________________________________________________________

SS#: _________________________________________________________ DOB: ________________________________________________

Signature: __________________________________________________ Date: _________________________________________________

Revised 11/01/13

EMPLOYMENT DATA FORM

Name SS# Address D.O.B.

Gender Race City, State, Zip

Home Phone # Cell Phone #

Position Employment Date Full-Time Part-Time Highest Degree Held I am an active member of an Alabama Retirement System ( )TRS ( )ERS ( )N/A In case of emergency, please notify: Name Relationship Phone

OR

Name Relationship Phone Note: The above information is for Human Resources use only. It is only requested of applicants who have been offered and accepted employment. Employee Number ____________________________________ Revised 10/25/13

Emergency Information

Date: __________________________

NEW EMPLOYEE EMAIL ADDRESS FORM

___________________________________ _______ ___________________________________

FIRST NAME M.I. LAST NAME

FULL-TIME PART-TIME _____________________________

DATE OF BIRTH

___________________________________________________

PERSONAL EMAIL ADDRESS

__________________________________________ ______________________

EMPLOYEE’S SIGNATURE DATE

FOR OFFICE USE ONLY

___________________________________________________

LAWSON STATE EMPLOYEE EMAIL ADDRESS

___________________________________________________

LAWSON STATE EMAIL PASSWORD ADDRESS

FAMILY RELATIONSHIP DISCLOSURE FORM

Employee’s Name: __________________________________________________ SSN: _______________________ Job Title/Position: _________________________________________________________________________________ Employment Date: ______________________________________ Full-Time _______ Part-Time _______ Salary Schedule __________ Rank _______ Step _______ Annual Salary __________________________ For purposes of this disclosure, relative includes the following: spouse, dependent, adult child and his or her spouse, parent, spouse’s parents, sibling and his or her spouse. Are you a relative of any employee of the Alabama College System, including Lawson State Community College, or any member of the State Board of Education? Yes ______ No ______ If yes, list the name(s), relationship, and employer/position of relative(s)

I affirm that all information contained herein is correct to the best of my knowledge. Sign: _________________________________________________________________ ________________________ Employee’s Signature Date

Revised 10/10/12

Conflict of Interest and Outside Employment

Statement of Compliance

615.01 Conflict of Interest (State Board guidelines available) Full-time employees of Lawson State may, with approvals described below, contract to

perform independent research, to furnish services as a consultant, or both, provided that

such activity: (a) does not interfere with the performance of other responsibilities as a

Lawson State Community College employee; (b) is limited in time; (c) is compatible with

the interests of Lawson State; and (d) does not require use of institutional resources or

facilities.

Written prior approval to participate in any outside consulting activities shall be obtained

from the President through the appropriate Department or Division Chair and Dean.

Activities which shall be exempt from the requirement for prior approval include those

things which, assuming they do not constitute a conflict of interest or conflict of

commitment, are generally recognized as professional responsibilities, and do not involve

the use of institutional resources.

All other external consulting activities which draw upon the knowledge and skill of an

employee require prior approval.

My signature on this document verifies that I have received from Lawson State Community

College, institutional policies regarding conflict of interest and outside employment. I

understand clearly that it is my responsibility to comply with the requirements of these

policies on conflict of interest and outside employment.

Further, it is my understanding that failure to comply with the requirements of these

policies will be considered as a disregard for the College’s authority and may be considered

as insubordination which could lead to disciplinary actions ranging from a written request

for corrective action to dismissal.

Printed Name: _____________________________________________

Signature: ______________________________________________ Date: ______________________________

Revised 10/11/12

Alabama Community College System Application No.

APPLICATION FOR EMPLOYMENT

LAWSON STATE COMMUNITY COLLEGE

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Title of position for which you are applying:

Date of Application

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Last Name First Name Middle Initial

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Contact Information

Phone: Home Work Cell E-mail Address

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Major Minor Degree(s) Earned

High School/ GED

College

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Please list most recent employment experience first.

Employer Telephone Number

Job Duties

Address Dates of Employment

Title Full-time Part-time Hourly Rate/Salary

Reason for Leaving

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May we contact your current employer? Yes No

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Please list three references, other than relatives, who can provide information verifying qualifications, character, or work experience.

Name and Title Address Phone Number

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For the purposes of disclosure, relative includes the following: spouse, dependent, adult child and his or her spouse, parent, spouse’s parents, sibling and his or her spouse. Are you a relative of any employee in the Alabama Community College system, including (name of college), or any member of the State Board of Education? Yes No If yes, list the name(s), relationship, and employer/position of relative(s):

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Have you ever been convicted of or pled no contest or guilty to any felony or any crime involving theft, dishonesty, violence, or sexual misconduct? Yes No If yes, explain below:

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I represent and warrant that the information I have given on this application is full and true to the best of my knowledge and belief. I further acknowledge that I understand that I must provide documented verification of education, experience, and required certifications and/or licensures. And further, I represent and warrant that I have answered fully and truthfully al l questions regarding criminal convictions/records. I understand that any offer of employment is contingent upon a satisfactory criminal background investigation and I hereby authorize my employing authority within the Alabama Community College System and/or its assigns to conduct a criminal background history investigation. I understand that in the event a conviction for a felony or any crime involving moral turpitude is found that the procedures set out in the guidelines for State Board Policy 623.01 will be followed. I further understand that I will be responsible for the cost of said criminal background check. I hereby expressly request, and give permission to, former employers and any

persons who may have pertinent information concerning this application to furnish such information to college officials. I agree to hold such persons harmless, and I do hereby release them from any and all liability for damage of any nature whatsoever for furnishing such information. I understand that failure to provide full and true information on this application may result in disqualification or dismissal.

Signature of Applicant Date

Are you a member of the Alabama Community College System Applicant Pool? Yes No

Lawson State Community College Attention Human Resources

3060 Wilson Road, SW Birmingham, Alabama 35221

(205) 925-2515

It is the policy of the Alabama Department of Postsecondary Education, including all postsecondary institutions under the control of the Alabama State Board of Education, that no person shall, on the grounds of race, color, disability, sex, religion, creed, national origin, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program, activity, or employment. (Each institution will make reasonable accommodations for qualified disabled applicants or employees.)

_______________________

EQUAL EMPLOYMENT OPPORTUNITY INFORMATION

The following information is gathered solely for reporting purposes and will not be used to evaluate the applicant’s qualifications, suitability, or desirability for employment.

Name _____________________________________________________________________ Last First Middle

SS # ____________________________________ Date of Birth _________________

Ethnic Background (check one): Gender (check one):

( ) Native American ( ) Male ( ) White, not of Hispanic origin ( ) Female ( ) Hispanic ( ) Black, not of Hispanic origin ( ) Asian/Pacific Islander ( ) Multi-racial ( ) Other

MISCELLANEOUS INFORMATION

Have you ever been employed by the College? ( ) Yes ( ) No

Position: _______________________________ Employed from __________to __________

______________________________ Referral Source

( ) Advertisement ( ) Friend ( ) Relative ( ) Walk-In

( ) Employment Agency ( ) LSCC Website ( ) Other: ___________________

_________________________

DRUG-FREE WORKPLACE POLICY

In compliance with the drug-free workplace requirements of Public Law 100-690 for recipients of Federal contracts and grants, the following policy is in effect for Lawson State Community College: 1. The unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance is

prohibited by Lawson State Community College on any property owned, leased, or controlled by Lawson State Community College or during any activity conducted, sponsored, or authorized by or on behalf of Lawson State Community College. A “controlled substance” shall include any substance defined as a controlled substance in Section 102 of the Federal Controlled Substance Act (21 U.S. Code 802) or in the Alabama uniform Controlled Substance Act (Code of Alabama, Section 20-2-1, et. seq.).

2. Lawson State Community College has and shall maintain a drug-free awareness program to inform

employees about the following: a) The dangers of drug abuse in the workplace; b) Lawson State Community College’s policy of maintaining a drug-free workplace. c) Any available drug counseling, rehabilitation, and employee assistance program; and d) The penalties that may be imposed upon employees for drug abuse violations. 3. All employees of Lawson State Community College shall comply with paragraph 1 above. 4. Any employee who is convicted by any Federal or State Court of an offense which constitutes a violation

of paragraph 1 above shall notify President Perry Ward in writing of said conviction within five (5) days after the conviction occurs. Conviction, as defined in P.L. 100-690, shall mean “a finding of guilt (including a plea of nolo contendere) or imposition of a sentence, or both.”

5. In the event of a report of a conviction pursuant to paragraph 4 above where the employee is working

in a project or a program funded through a Federal contract or grant, Lawson State Community College shall notify in writing within ten (10) days any Federal agency to whom such notification by Lawson State Community College is required under P.L. 100-690.

6. In the event an employee violates paragraph 1 above or receives a conviction as described in paragraph 4

above, the respective employee shall be subject to appropriate disciplinary action which may include, but is not limited to, termination of employment. Lawson State Community College shall also reserve the right to require said employee, as a condition of continued employment, to satisfactorily complete a drug treatment or rehabilitation program of a reasonable duration and nature.

7. Lawson State Community College shall make a good faith effort to ensure that paragraphs 1-6 above are followed. 8. Each employee of Lawson State Community College shall receive a copy of this policy. My signature below affirms that I have received, read, and understand this Drug-Free Workplace Policy. Printed Name __________________________________________________________________________ Employee’s Signature ________________________________________________________________ Date ______________________________

Revised 10/10/12

HARASSMENT POLICY ACKNOWLEDGEMENT

601.04 HARASSMENT (State Board guidelines available) Lawson State Community College does not authorize and will not tolerate any form of discrimination or harassment of or by any employee (i.e., supervisory or non-supervisory) or non-employee based on race, sex, religion, color, national origin, age, disability, or any other factor protected by law. An employee’s race, sex, religion, color, national origin, age, disability or any other factor protected by law, may not be considered as a basis for making any employment decisions regarding the employee, including, but not limited to, any decisions relating to hiring, promotion, training, job assignments, compensation, discipline, discharge, and other terms and conditions of employment. The term “harassment” includes, but is not limited to, offensive language, jokes, or other verbal, graphic or physical conduct; or intimidating, threatening or offensive behavior relating to an employee’s race, sex, religion, color, national origin, age, disability, sex or other factors protected by the College’s policy and law which would make the reasonable person experiencing such harassment uncomfortable in the work environment or which could interfere with the person’s job performance.

This policy applies to each and every employee at the College. It is the College’s policy that all employees and students have a right to work and learn in an environment free of discrimination, which encompasses freedom from any form of harassment. This includes the behavior of peers, superiors, subordinates, and visitors to the premises. Such conduct by an employee may result in disciplinary action up to and including dismissal.

PROGRESSIVE DISCIPLINE PROCEDURE

It is the policy of Lawson State Community College to use a four-step progressive discipline system to correct

unsatisfactory behavior or performance by college employees.

The following steps of progressive discipline will be implemented:

1. A verbal warning for a first offense. (Puts the employee on notice of his/her problems.) 2. A written warning if the problem continues. (Allows the employee the opportunity to correct his/her behavior.) 3. Possible suspension. (Alerts the employee to the consequences of not improving.) 4. Termination if the problem persists. (Creates a record of the problems.)

I, ____________________________________________________________________________________, the undersigned, hereby

acknowledge receipt of the College’s Harassment Policy as set forth in the Board of Education policies

and procedures governing the Alabama Community College System. I also further understand that

violation of this policy may result in disciplinary action and/or possible termination.

________________________________________________________________________ _____________________________________

Signature Date

NOTE: Please print your name on first line. Revised 10/10/12

POLICY NAME: 809.01: Student Records: General

EFFECTIVE: 03-24-05

SUPERSEDES: 809.01 issued 01-13-94

SOURCE:

CROSS REFERENCE:

The Family Education Rights and Privacy Act of 1974 (PL 93-380), known as the Buckley Amendment, shall apply to the handling of student records at all institutions. Indicated by my signature below I, __________________________________________________________ have received a brochure of the Family Education Rights and Privacy Act of 1974 (FERPA) known as the Buckley Amendment. I also agree it is my responsibility to read, understand and abide by this policy when handling student records as indicated in the Family Education Rights and Privacy Act of 1974 (FERPA). ______________________________________________________ ________________________________ Employee Signature Date

Family Education Rights and Privacy Act Acknowledgement Form

Lawson State Community College Direct Deposit Enrollment Form

Authorization Agreement for Direct Deposits (ACH Credits)

Employee Name______________________________________ SS# _________________________________

I hereby authorize Lawson State Community College to initiate credit entries and to initiate debit entries and adjustments for any credit entries made in error to my account. Please indicate the depository or financial institution named below, hereinafter call DEPOSITORY, and to credit the same to such account.(s) DEPOSITORY #1 DEPOSITORY #2 Name: ____________________________ Name: _____________________________ Routing # ________________________ Routing # _________________________ Account # _______________________ Account # _________________________ Amount $ ________________________ Amount $ ___________________________ Account Type ( ) Checking ( ) Savings Account Type ( ) Checking ( ) Savings

DEPOSITORY #3 ( ) Paysource VISA/Debit Card Amount $ ____________________ This authorization is to remain in full force and effect until Lawson State Community College has received written notification from me of its termination in such time and in such manner as to afford Lawson State Community College a reasonable opportunity to act on it. This form must be accompanied with voided check. (No deposit slips for checking account deposits!) All savings account deposits must be accompanied by the appropriate form from your banks. ____________________________________________________ ______________________ Employee’s Signature Date

BAO USE ONLY

Check/Form Attached ( ) Yes No ( ) _________________

Revised 10/10/12

BAO USE ONLY

Check /Form Attached: ( ) Yes ( ) No Date: ____________

By: ____________

PLEASE CUT HERE

Employee: Complete Form A-4 and file it with your employer. Otherwise, tax will be with-held without exemption.

Employer: Keep this certificate on file. If an employee is believed to have claimed moreexemptions than that which they are legally entitled to claim, the Department should benotified. Any correspondence concerning this form should be sent to the AL Dept of Rev-enue, Withholding Tax Section, PO Box 327480, Montgomery, AL 36132-7480 or by fax to334-242-0112. Please include contact information with your correspondence.

Penalties: Section 40-18-73, Code of Alabama 1975. Every employee, on or before thedate of commencement of employment, shall furnish his or her employer with a signed Ala-bama withholding exemption certificate relating to the number of withholding exemptionswhich he or she claims, which in no event shall exceed the number to which the employeeis entitled. In the event the employee inflates the number of exemptions allowed by thisChapter on Form A-4, the employee shall pay a penalty of five hundred dollars ($500) forsuch action pursuant to Section 40-29-75.

Exempt Status: Military Spouses Residency Relief Act. This exemption applies to aspouse of a US Armed Service member who is present in Alabama in compliance with mil-itary orders and who maintains domicile in another state. Employee should provide their em-ployer with valid military identification and a copy of a current leave and earnings statementor Form DD-2058. Complete line 6 on front of Form A-4 if you qualify for this exemption.

Exempt Status: No tax liability. An exemption from withholding may be claimed if you filedan Alabama income tax return in the prior year, had a zero tax liability on that return, andyou anticipate a zero tax liability on your current year return. If you had any tax withheld inthe prior year and did not receive a full refund of that amount, you will not qualify and shouldcomplete the front of Form A-4.

CHANGES IN EXEMPTIONS: You may file a new certificate at any time if the number ofyour exemptions INCREASE. You must file a new certificate within 10 days if the numberof exemptions previously claimed by you DECREASES for any of the following reasons:

(a) Your spouse for whom you have been claiming exemption is divorced, legally sepa-rated, or claims her or his own exemption on a separate certificate.

(b) You no longer provide more than half of the support for someone you previously claimeda dependent exemption for.

DECREASES in exemption, such as the death of a spouse or dependent, will not requirethe filing of a new exemption certificate until the following year.

DEPENDENTS: To qualify as your dependent (Line 4 on other side), a person must receivemore than one-half of his or her support from you for the year and must be related to youas follows:

Your son or daughter (including legally adopted children), grandchild, stepson, step-daughter, son-in-law, or daughter-in-law;

Your father, mother, grandparent, stepfather, stepmother, father-in-law, or mother-in-law;

Your brother, sister, stepbrother, stepsister, half brother, half sister, brother-in-law, or sister-in-law;

Your uncle, aunt, nephew, or niece (but only if related by blood).

THIS FORM MAY BE REPRODUCED.

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. See reverse side for penalty details.

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS

1. If you claim no personal exemption for yourself and wish to withhold at the highest rate, write the figure “0”, sign and date Form A-4 and file it with your employer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. If you are SINGLE or MARRIED FILING SEPARATELY, a $1,500 personal exemption is allowed. Write the letter “S” if claiming the SINGLE exemption or

“MS” if claiming the MARRIED FILING SEPARATELY exemption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. If you are MARRIED or SINGLE CLAIMING HEAD OF FAMILY, a $3,000 personal exemption is allowed. Write the letter “M” if you are claiming an exemption for both yourself and

your spouse or “H” if you are single with qualifying dependents and are claiming the HEAD OF FAMILY exemption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Number of dependents (other than spouse) that you will provide more than one-half of the support for during the year. See instructions for dependent qualifications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Additional amount, if any, you want deducted each pay period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6. Exempt Status: If you meet the conditions set forth under the Military Spouses Residency Relief Act and will have no Alabama income tax liability, skip lines 1-5, write “EXEMPT” on

line 6, sign and date Form A-4 and file it with your employer. See instructions on the back of Form A-4 for the documentation you must provide to your employer in order to qualify. . . . . . . . . . . . . . . . .

7. Exempt Status: If you had no Alabama income tax liability last year and you anticipate no Alabama income tax liability this year, you may claim an exemption from Alabama

withholding tax. Skip lines 1-6, write “EXEMPT” on line 7, sign and date Form A-4 and file it with your employer. See instructions on the back of Form A-4 to be sure you qualify. . . . . . . . . . . . . . . . . . . .

LINE 8 BELOW TO BE COMPLETED BY YOUR EMPLOYER

8. TOTAL EXEMPTIONS (Example: Employee claims “M” on line 3 and 2 on line 4. Employer should use column headed M-2 in the Withholding Tax Tables and Instructions for Employers.) . . . . . . . . . .

ALABAMA DEPARTMENT OF REVENUEEmployee’s Withholding Exemption Certificate

EMPLOYEE’S FULL NAME SOCIAL SECURITY NO.

HOME ADDRESS CITY STATE ZIP CODE

SIGNED DATE

FORM

A-4

EMPLOYER NAME EMPLOYER FEIN EMPLOYER STATE ID

$

REV. 11/10

Form W-4 (2012)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 2012 expires February 18, 2013. 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 cannot claim exemption from withholding if your income exceeds $950 and includes more than $300 of unearned income (for example, interest and dividends).

Basic instructions. If you are not 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 2012. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).

Future developments. The IRS has created a page on IRS.gov for information about Form W-4, at www.irs.gov/w4. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted on that page.

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 are single and have only one job; or• You are married, have only one job, and your spouse does not work; or . . .• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} BC 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.) . . . . . . . . . . . . . . CD 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 $1,900 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 $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three to seven eligible children or less “2” if you have eight or more eligible children.

• If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible child . . . GH 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 $40,000 ($10,000 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

20121 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 2012, 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 (2012)

Form W-4 (2012) Page 2 Deductions and Adjustments Worksheet

Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

1 Enter an estimate of your 2012 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and miscellaneous deductions . . . . . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $11,900 if married filing jointly or qualifying widow(er)$8,700 if head of household . . . . . . . . . . .$5,950 if single or married filing separately

} 2 $3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2012 adjustments to income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2012 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2012 nonwage income (such as dividends or interest) . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $8 Divide the amount on line 7 by $3,800 and enter the result here. Drop any fraction . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

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

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

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

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

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

4 Enter the number from line 2 of this worksheet . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $9 Divide line 8 by the number of pay periods remaining in 2012. For example, divide by 26 if you are paid

every two weeks and you complete this form in December 2011. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck . . . . . . . . 9 $

Table 1Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $5,000 05,001 - 12,000 1

12,001 - 22,000 222,001 - 25,000 325,001 - 30,000 430,001 - 40,000 540,001 - 48,000 648,001 - 55,000 755,001 - 65,000 865,001 - 72,000 972,001 - 85,000 1085,001 - 97,000 1197,001 - 110,000 12

110,001 - 120,000 13120,001 - 135,000 14135,001 and over 15

All Others

If wages from LOWEST paying job are—


$0 - $8,000 08,001 - 15,000 1

15,001 - 25,000 225,001 - 30,000 330,001 - 40,000 440,001 - 50,000 550,001 - 65,000 665,001 - 80,000 780,001 - 95,000 895,001 - 120,000 9

120,001 and over 10

Table 2Married Filing Jointly

If wages from HIGHEST paying job are—


$0 - $70,000 $57070,001 - 125,000 950

125,001 - 190,000 1,060190,001 - 340,000 1,250

340,001 and over 1,330

All Others

If wages from HIGHEST paying job are—


$0 - $35,000 $57035,001 - 90,000 95090,001 - 170,000 1,060

170,001 - 375,000 1,250 375,001 and over 1,330

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

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

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

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

Welcome to the Lawson State Community College Family!

As a Lawson State employee you are required to view the Ethics Training Video via

the website at http://ethics.alabama.gov/Training/LawUpdate.aspx. Please print your certificate at the end of the video, sign it and forward it to the

Birmingham Human Resources Office for file. You may choose to scan your signed certificate as a pdf and email to [email protected]. If you choose not to view the video via the link provided, we will schedule a day for group training

and you will have an opportunity to watch the video at that time.

If you have any problems or need additional assistance, please feel free to contact me at ext. 6308.

Thank you in advance for your cooperation.

Human Resources Office

http://ethics.alabama.gov/Training/LawUpdate.aspx

Welcome to the Lawson State Community College Family!

All employees must have official transcripts of ALL degrees earned in their personnel files.

Please adhere to the following college practices.

Failure to do so can result in delay of compensation or termination of employment.

STEP 1: Unofficial copies of transcripts and/or any applicable licenses/certifications are acceptable for the interview and screening process. STEP 2: A request for OFFICIAL TRANSCRIPTS should be submitted to ALL colleges you attended. ALL certifications/licenses or other educational materials required for employment should also be submitted.

TRANSCRIPTS should be submitted to:

LAWSON STATE COMMUNITY COLLEGE ATTN: Mrs. Janice McGee, Director

Human Resources Office 3060 Wilson Road, SW

Birmingham, AL 35221 If you have questions about this process, contact your immediate

supervisor or appropriate Administrator.

http://tm.ask.com/r?t=an&s=p&uid=0B7DBA2E2893D5224&sid=1730A9692442DAE34&o=312&qid=826D5D95DADE8505C6EF42FE4835E803&io=13&sv=0a300525&ask=transcript+request&uip=42196e66&en=pi&eo=&pt=&ac=24&qs=31&pg=8&u=http%3A%2F%2Fpictures.ask.com%2Ffr%3Fq%3Dtranscript%2Brequest%26desturi%3Dhttp%253A%252F%252Fwww.biblical-life.com%252Fservices.htm%26fm%3Di%26ac%3D24%26ftURI%3Dhttp%253A%252F%252Fpictures.ask.com%253A80%252Ffr%253Fq%253Dtranscript%252Brequest%2526desturi%253Dhttp%25253A%25252F%25252Fwww.biblical-life.com%25252Fservices.htm%2526imagesrc%253Dhttp%25253A%25252F%25252Fwww.biblical-life.com%25252Fimages%25252Ftranscript.gif%2526thumbsrc%253Dhttp%25253A%25252F%25252F65.214.37.88%25252Fts%25253Ft%25253D5128348707340269101%2526fn%253Dtranscript.gif%2526f%253D2%2526fm%253Di%2526ftbURI%253Dhttp%25253A%25252F%25252Fpictures.ask.com%25252Fpictures%25253Fq%25253Dtranscript%25252Brequest%252526page%25253D8%26qt%3D0

OFFICIAL TRANSCRIPT REQUEST FORM

We are excited to have you on our team of highly qualified professionals at Lawson State Community College. As a Lawson State employee, you are required to submit OFFICIAL TRANSCRIPTS for ALL degrees, certificates or diplomas earned (beyond your high school years) to our Human Resources Office. Please mail or deliver (unopened) OFFICIAL TRANSCRIPTS within 14 days of your hire date to: Lawson State Community College Mrs. Janice McGee, Director of Human Resources Human Resources Office 3060 Wilson Road Birmingham, AL 35221 --------------------------------------------------------------------------------------------------------------------- DETACHABLE FORM –CUT BELOW AND USE TO SECURE TRANSCRIPTS --------------------------------------------------------------------------------------------------------------------- PLEASE SEND A COPY OF MY OFFICIAL TRANSCRIPTS TO: Lawson State Community College Mrs. Janice McGee, Director of Human Resources Human Resources Office 3060 Wilson Road, SW Birmingham, AL 35221 Student’s Name: Student’s Maiden Name (if applicable): Dates of Attendance: Social Security Number: Major: Degree Earned: Student’s Current Phone: ( ) Student’s Current Address: Student’s Signature: Date:

The Family Educational Rights and Privacy Act of 1974 is a federal law regarding the privacy of student

education records. The Act provides students the right to inspect and review educational records, the

right to seek to amend those records, and the right to limit disclosure of information from the records.

WHAT IS DIRECTORY INFORMATION?

FERPA requires colleges and universities to define the information that they will release without a

student’s prior written consent. Lawson State Community College’s definition contains a list of those

“directory information” items that we MAY release. They are as follows:

One common misconception is that FERPA requires us to release student information. It does not.

Accordingly, you should err on the side of not releasing information when you are in doubt. You should

always feel free to ask your immediate supervisor for assistance before releasing the requested information.

You can always direct questions to the Office of Student Records.

If a student does not wish the directory information released, he or she may indicate by notifying the

Registrar in writing at the time of registration, and the College will withhold the information during that

particular semester. The request for nondisclosure of directory information should be renewed each

semester.

FERPA pertains to everyone who works at Lawson State Community College, regardless of his or her

position. What FERPA says, in effect, is that we may all have access to as much information about students

as we need to do our jobs. Clearly, many people who work at the College have no access to student

records and have no need for individual student information. Some of the same people, however, may

come across confidential information in the course of doing their job. The maintenance staff, for example,

may come across confidential information about students. They are equally obligated, as we are, to respect

its confidentiality.

Bessemer Campus

1100 9th Avenue SW

Bessemer, Alabama 35022

Phone: 205-929-3409

Fax: 205-929-3602

Birmingham Campus

3060 Wilson Road

Birmingham, Alabama 35221

Phone: 205-925-2515

Fax: 205-923-7106

www.lawsonstate.edu

Revised 07/15/2008

Student's name, address (local and

permanent), and telephone number.

Parents and Spouse.

Date and place of birth.

Major field of study.

Participation in officially recognized

activities and sports.

Weight and height statistics for athletic

team members.

Dates of attendance.

Degrees and awards received.

Previous educational institution most

recently attendance.

Photographs.

It is the policy of the Alabama State Board of Education and

Lawson State Community College, a postsecondary institution

under its control, that no person shall, on the grounds of race,

color, sex, religion, national origin, disability or age, be excluded

from participation in, be denied the benefits of, or be subjected

to discrimination under any program, activity, or employment.

Family Educational Rights

and Privacy Act

Guidelines for

Lawson State Community

College

Faculty/Staff

Faculty/staff should not provide copies to students of

their transcripts from other institutions. If you release

copies of transcripts, you are acting as a third party

testifying as to the accuracy of

the information on the

transcripts.

F a c u l t y / s t a f f s h o u l d

understand that only the

Office of Student Records

should release information

about a student’s educational

record to a third party

outside the College.

Faculty/staff should not share

non directory information

from a student’s education records, such as grades,

attendance or class schedules, with parents. You may

always refer the parents to the Office of Student Rec-

ords.

Faculty/staff should refer all judicial orders, subpoenas or

other written requests for access to information or data

subject to the Freedom of Information Act immediately

to the Office of Student Records.

Faculty/staff should not include “educational

record” (grades, GPA and other non-directory

information) information in a letter of recommendation

without written permission of the student.

Faculty/staff should not publicly post grades either by the

student’s name, student identification number or social

security number. This is a violation of FERPA even if the

names are obscured. Faculty can assign students unique

numbers or codes that can be used to post grades but

the order of the posting must not be alphabetic.

When in doubt, ASK. Faculty/staff should not release

information to others when in doubt. Consult with the

Office of Student Records.

Beyond any legal requirements, Lawson State

Community College is bound by professional

ethics to safeguard the integrity and confidentiality

in an administrative, supervisory, academic or

research, or support staff position, regardless of

their work classification or full-time, part-time or

temporary. What follows are some guidelines in

compliance with FERPA regulation and Lawson

State Community College policy to follow in order

to maintain, report and make available information

included in student educational records.

Faculty/staff may have access to all the information

they need to do their jobs; but have no right to

any information not needed to do their jobs. Use

a “need to know” (rather than a “right to know”)

approach when accessing students’ education

records. Faculty/staff must have a legitimate

college-related educational or administrative

interest (e.g. advising students, retention study,

etc.) and a need to review an education record in

order to fulfill their professional responsibility.

Faculty/staff must take reasonable precautions to

safeguard access to student information. These

include shredding documents, not sharing

computer IDs and passwords, not allowing anyone

else to do work under our IDs and passwords, and

not leaving the student information system (AS400

or Faculty Web Suite) up and running and

accessible when away from computers.

WHAT ARE YOUR

RESPONSIBILITIES AS A

FACULTY MEMBER

? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?

DOS

DO refer requests to the Office of Student

Records when you are uncertain how to

respond.

DO release a student’s information to him or

her when you can positively identify the

student. (Be cautious! Positive IDs cannot

generally be made via telephone or e-mail.)

DO post grades on Blackboard.

DO refer parental requests for student

record information to the Office of

Student Records.

DO shred unneeded confidential documents.

DON’TS

DON’T provide non-directory information

including grades, GPA, and class schedules

with any unauthorized third party, including

parents, without written consent from the

student.

DON’T post grades by names, social security

numbers, PINS, or any combination thereof

on walls, doors, or unauthorized websites.

DON’T view education records for personal

reasons.

Faculty/staff should not distribute graded work

in a way that exposes the student’s identity

(such as on a web site) or leave personally

identifiable, graded papers unattended. This is

no different from posting grades publicly. If the

papers contain personally identifiable

information, then leaving them unattended for

anyone to see is a violation of FERPA. Possible

solutions for distributing grade information to

students would be to leave the graded papers

(exams, quizzes, and homework) with an

assistant or secretary who would ask students

for proper identification prior to distributing

them, leave graded work in a sealed envelope

with only the student’s name on it, or use a

code name or number known only to the

student and faculty member to identify graded

work.

Notification of grades via a postcard violates a

student’s privacy. While notification of grades

via email is permissible under FERPA, Lawson

State prohibits emailing or mailing of grades.

Positive IDs cannot generally be

made via telephone or e-mail

General questions may be directed to the Office

of Students Records. Comments or suggestions

should be addressed to [email protected]

or by calling 205-929-3409.

mailto:[email protected]

New_Hire_Faculty_Credentials_ Approval_Form.pdfFaculty_Credentials_Intent_to_Hire_Form.pdfA_4_State_Tax_FormBackground_Check_FormConflict_of Interest_and_Outside_Employment_FormDirect_Deposit_FormDrug_Free_Workplace_PolicyEmployment_Data_FormEthics_Certificate_Retrieval_InstructionsExit_Interview_FormFamily_Relationship_Disclosure_FormFMLA_Designation_Notice_Form_WH_382Notice of Eligibility and Rights & Responsibilities

FMLA_Employee_Rights_ResponsibilitiesFMLA_Leave_RequestFMLA_ProceduresHarrassment_Policy_FormLawson_State_Employment_ApplicationNew_Employee_Email_Address_FormNew_Health_Insurance_Marketplace_CoveragePART B: Information About Health Coverage Offered by Your Employer

PEEHIP_Enrollment_FormPEEHIP_Enrollment_InstructionsTranscript Request Instructions and FormTranscript_Request_FormTranscript_Request_InstructionsTRS_Form_100W_4_Federal_Tax_Form

FERPA_Brochure.pdfFERPA_Acknowledment_Form.pdf

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Reset: Name: SSN: Address: City: State: ZIP: Date: 1: 2: 3: 4: 5: 6: 7: 8: EmployerName: EmployerFEIN: EmployerStateID:

faculty credentials/intent to hire form...faculty credentials/intent to hire form (all original...

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