requirements pamela conklin live scan fingerprint service … · 2019-05-23 · coaches application...

COACHES APPLICATION CHECKLIST

Pamela Conklin Superintendent

2751 De Ronde Drive Fairfield, CA 94533

(707) 437-4604

Cambridge Elementary School 100 Cambridge Dr, Vacaville

(707) 446-9494

Center Elementary School 3101 Markeley Ln, Fairfield

(707) 437-4621

Foxboro Elementary School 600 Morning Glory Dr, Vacaville

(707) 447-7883

Golden West Middle School 2651 De Ronde Dr, Fairfield

(707) 437-8240

Scandia Elementary School 100 Broadway St, Travis AFB

(707) 437-4691

Travis Community Day School 2785 De Ronde Dr, Fairfield

(707) 437-8265

Travis Elementary School 100 Fairfield Ave, Travis AFB

(707) 437-2070

Travis Education Center 2775 De Ronde Dr, Fairfield

(707) 437-8265

Vanden High School 2951 Markeley Ln, Fairfield

(707) 437-7333

Governing Board Russ Barrington Riitta DeAnda

Ivery Hood Janet Jackson Forbes

REQUIREMENTS: Activity Supervisor Clearance Certificate

Live Scan Fingerprint service https://calendly.com/tusdlivescan/livescan Certificated live scan fee- $49

ASCC Application from Commission on Teacher Credentialing

https://www.ctc.ca.gov/docs/default-source/leaflets/cl891.pdf?sfvrsn=0

Please provide the following credentials:

CPR/ First Aid Certification

Valid on: _____ / ______ / _____ Expiration Date: ____ / _____ / _____

Concussion in Sports Certificate https://nfhslearn.com/courses/61129/concussion-in-sports


Sudden Cardiac Arrest Certificate: https://www.sportsafetyinternational.org/cardiacwise/


Heat Illness Training: Valid on: ____ / ______ / ______ Expiration Date: ____ / _____ / ______

Fundamentals of Coaching (CIF Certification Certificate) https://nfhslearn.com/courses/61113/fundamentals-of-coaching


Acknowledgment of Receipt - Coaches Handbook https://www.travisusd.org/Page/2307

Verification of a negative tuberculosis results *Read within the last four (4) years

Adrian Saiz

Coach Application Packet 1/2019

https://calendly.com/tusdlivescan/livescanhttps://www.sportsafetyinternational.org/cardiacwise/https://nfhslearn.com/courses/61113/fundamentals-of-coachinghttp://www.travisusd.org/Page/2307

TRAVIS UNIFIED SCHOOL DISTRICT

APPLICANT DATA RECORD

Qualified applicants are considered for all positions without regard to race, color, religion, sex, national

origin, age, marital or veteran status, medical condition or handicap.

The Travis Unified School District is an Equal Opportunity Employer.

Solely, to help us comply with governmental record keeping and other legal requirements, the District

requests that you fill out this Applicant Data Record. It will be kept in a confidential file separate from the

application for Employment.

Date:

Position(s) Applied For:

Referral Source: Advertisement Friend Relative Edjoin.org

University Placement Office Other

Name: Phone:

Last First M.I.

Address:

Number Street City State Zip

Sex: Female Male

Race/Ethnic Group:

Black or African American (600)

American Indian or Alaskan Native (100)

Asian/Asian American

Filipino/Filipino American (400)

Hispanic/Latino (500)

Pacific Islander (PI)

White

Check if any of the following are applicable:

Vietnam Era Veteran Disabled Veteran Handicapped

In addition to the federal minimum individual categories, California Government Code Section 8310.5 requires state agencies to collect data for

each major Asian and Pacific Islander group, including, but not limited to, Chinese, Japanese, Korean, Vietnamese, Asian Indian, Laotian,

Cambodian, Filipino, Hmong, Hawaiian, Guamanian, Samoan, and Tahitian.

If Asian or Pacific Islander is marked

on the left, then select all that apply

Chinese (201) Guamanian (302)

Japanese (202) Samoan (303)

Korean (203) Laotian (206)

Vietnamese (204) Cambodian (207)

Asian Indian (205) Other Asian (299)

Hawaiian/Other PI (301) Hmong

PERSONAL DATA

COACH APPLICATION 2751 De Ronde Drive, Fairfield, CA 94533‐9710

707.437.4604 / 707.437.8122 (Fax)

Clear

Last Name First Middle

Present Address City Zip

Home Phone Cell Phone Email Address

Have you ever been employed by Travis Unified School District before?

If yes, please provide the dates:

Yes No

Do you have any friends or relatives working in the district?

If yes, list the name(s):

Yes No

COACHING EXPERIENCE

School/District Position/Sport Work Performed

Address City/State Zip

Supervisor Name Telephone Number

Reason for Leaving

EQUAL OPPORTUNITY EMPLOYER 1 Revised 8.2.18

Give name, address, and phone number of three (3) references not related to you.

Name Occupation Phone / Email Address

Site/Sport: Coaching position applying for:

EQUAL OPPORTUNITY EMPLOYER 2 Revised 8.2.18

Summarize special skills, qualifications, and/or experiences:

If “Yes,” list all convictions including, but not limited to convictions for “driving under the influence,” and convictions for sex and/or drug offenses listed in California Education Code Sections 44010 and 44011, except for convictions related to marijuana if it is more than two years after the date of the conviction. Include any serious or violent felony conviction in any state or jurisdiction as enumerated in California Penal Code sections 667.6(c) and 1192.7(c).

No Yes

The following information is REQUIRED for your application to be considered. Your answers will not necessarily disqualify you from consideration, except for affirmative responses to certain enumerated sex and/or drug convictions and/or convictions for committing serious and/or violent felonies. Explain all “Yes” answers in the spaces below.

Have you ever been convicted of a felony or misdemeanor, other than a conviction related to marijuana if it is more than two years after the date of the conviction, or do you currently have a felony or misdemeanor charge pending? Convictions include a plea of guilty, nolo contendere (no contest) and/or a finding of guilty by a judge or a jury.

Date Signature

Agreement

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements in this application for employment as may be necessary in arriving at

an employment decision. In the event of employment, I understand that false or misleading information given on my application or

interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulationof the school district.

Commission on Teacher Credentialing Page 1 of 1 ASCC Rev. 7/2012

Activity Supervisor Clearance Certificate

What is the Activity Supervisor Clearance Certificate? Everyone applying for the ASCC must use the online process; paper applications will not be accepted. You must be located in California and able to complete the Live Scan process to apply for the Activity Supervisor Clearance Certificate. If fingerprint cards are received they will be returned and fees will not be refunded.

Requirements for the Activity Supervisor Clearance Certificate:

□ Complete and print 3 copies of form 41-LS;

□ Take the copies of form 41-LS to a Live Scan station to have your fingerprints taken. Your fingerprints will be electronically forwarded to the Commission. Keep two copies of form 41-LS for your records;

□ Complete the online direct application for the Activity Supervisor Clearance Certificate and pay the nonrefundable application fee bycredit card; and

□ Submit applicable documentation as required for the Professional Fitness Questions. Documentation should be mailed to:

Commission on Teacher Credentialing Attn: Online Direct Applications1900 Capitol Avenue Sacramento, CA 95811-4213

NOTE: These requirements are for reference only. After having your fingerprints taken at a Livescan site, you do not need to mail supporting materials to the Commission unless you are submitting information as required for the Professional Fitness Questions.Professional Fitness questions will be answered as part of the Online Direct Application Process.

The Activity Supervisor Clearance Certificate is verification that you have cleared the Commission's professional fitness review process.

Return to Beginning of Document

Activity Supervisor Clearance Certificate Fingerprint Clearance

1. If not already completed, fill out the CTC-specific Form 41-LS and take 3 copies to a Live Scan station for your fingerprints to be taken. TRAVIS USD is a Live Scan operator.

2. Apply for your document using the CTC Online system at the Commission's website (www.ctc.ca.gov). Select Educator Login to begin. • If you have created an Educator Account after February 2017, please login with your User ID and

Password.

• If you have not created an Educator Account, please use the Create Educator Account link. Note: When an User ID has been created, it cannot be changed. For security purposes, never use your SSN

as your User ID.

Apply for a Document

3. Log in with your User ID and Password. 4. Continue to the Educator Page, which displays after the Legal Disclaimer and Personal Information pages. 5. Scroll down to the heading Apply for a Certificate of Clearance or Activity Supervisor Clearance Certificate.

Click on Create New to start.

https://www.ctc.ca.gov/docs/default-source/leaflets/41-ls.pdf?sfvrsn=0https://www.ctc.ca.gov/

EMERGENCY NOTIFICATION INFORMATION

Human Resources

Name: Please Print

Social Security Number: Last 4 Digits

Print below the name, address and telephone number of two people you wish to be contracted should you become disabled at work due to illness or injury.

1st Contact

Name of Emergency Contact

Relationship

Mailing Address

City State Zip

Telephone Number of Emergency Contact (Please include area code)

Home Work

Cell

2nd Contact

Name of Emergency Contact

Relationship

Mailing Address

City State Zip

Telephone Number of Emergency Contact (Please include area code)

Home Work

Cell

Signature Date

Emergency Notification_5.12.16

Travis Unified School District – 2751 De Ronde Dr. - Fairfield, CA 94533-9710

RECEIPT AND ACKNOWLEDGEMENT OF CHILD ABUSE REPORTING REQUIREMENTS

Human Resources


Child Abuse Reporting Requirements_9.25.18

As an employee of Travis Unified School District, I certify that I have been given a copy of Board

Policy relating to Child Abuse Reporting and Penal Code Sections 11164-11174.3. I have read and

understand the requirements for reporting known or suspected instances of child abuse and will

comply with these requirements. I further understand that failure to certify to these requirements

constitutes reason for non-employment.

Employee Name (Please Print)

Employee Signature Date

Legal Reference:

Board Policies:

California Penal Code Sections 11164- 11174.3

5141.4DO/PERS/0255

Important Information about Medical Care if You Have a

Work-Related Injury or Illness Complete Written Employee Notification Re: Medical Provider Network

(Title 8, California Code of Regulations, section 9767.12)

California law requires your employer to provide and pay for medical treatment if you are injured at work. Your employer has chosen to provide this medical care by using a Workers’ Compensation physician network called a Medical Provider Network (MPN). This MPN is administered by Networks By Design, Inc. This notification tells you what you need to know about the MPN program and describes your rights in choosing medical care for work-related injuries and illnesses.

● What happens if I get injured at work?

In case of an emergency, you should call 911 or go to the closest emergency room.

If you are injured at work, notify your employer as soon as possible. Your employer will provide you with a claim form. When you notify your employer that you have had a work-related injury, your employer or insurer will make an initial appointment with a doctor in the MPN.

● What is an MPN?

A Medical Provider Network (MPN) is a group of health care providers (physicians and other medical providers) used by your employer to treat workers injured on the job. MPNs must allow employees to have a choice of provider(s). Each MPN must include a mix of doctors specializing in work -related injuries and doctors with expertise in general areas of medicine.

● What MPN is used by my employer?

Your employer is using the NBSIA MPN with the identification number 2505. You must refer to the MPN name and the MPN identification number whenever you have questions or requests about the MPN.

● Who can I contact if I have questions about my MPN?

The MPN Contact listed in this notification will be able to answer your questions about the use of the MPN and will address any complaints regarding the MPN.

The contact for your MPN is:

Name: Networks By Design, Inc. Title: MPN Contact Address: P.O Box 820 Tracy, California 95376 Telephone Number: (877) 854-3353 Email address: [email protected]

General information regarding the MPN can also be found at the following website:

www.nbsiampn.org ● What if I need help finding and making an appointment with a doctor?

The MPN Medical Access Assistant will help you find available MPN physicians of your choice and can assist you with scheduling and confirming physician appointments. The Medical Access Assistant is available to assist you Monday through Saturday from 7am-8pm (Pacific) and schedule medical appointments during doctor's’ normal business hours. Assistance is available in English and in Spanish.

The contact information for the Medical Access Assistant is:

mailto:[email protected]://www.nbsiampn.org/

Toll Free Telephone Number: (877)854-3353 Fax Number: (209) 879-9387 Email Address: [email protected]

● How do I find out which doctors are in my MPN?

You can get a regional list of all MPN providers in your area by calling the MPN Contact or by going to our

website at: www.nbsiampn.org At minimum, the regional list must include a list of all MPN providers within 15 miles of your workplace and/or residence or a list of all MPN providers within the county where you live and/or work. You may choose which list you wish to receive. You also have the right to obtain a list of all the MPN providers upon request.

You can access the roster of all treating physicians in the MPN by going to the website at

www.nbsiampn.org ● How do I choose a provider?

Your employer or the insurer for your employer will arrange the initial medical evaluation with a MPN physician. After the first medical visit, you may continue to be treated by that doctor, or you may choose another doctor from the MPN. You may continue to choose doctors within the MPN for all of your medical care for this injury.

If appropriate, you may choose a specialist or ask your treating doctor for a referral to a specialist. Some specialists will only accept appointments with a referral from the treating doctor. Such specialists might be listed as “by referral only” in your MPN directory.

If you need help in finding a doctor or scheduling a medical appointment, you may call the Medical Access Assistant.

● Can I change providers?

Yes. You can change providers within the MPN for any reason, but the providers you choose should be appropriate to treat your injury. Contact the MPN Contact or your claims adjuster if you want to change your treating physician.

● What standards does the MPN have to meet?

The MPN has providers for the zip codes in the following counties in California: Napa, Yolo and Solano and 30 miles surrounding those zip codes.

The MPN must give you access to a regional list of providers that includes at least three physicians in each specialty commonly used to treat work injuries/illnesses in your industry. The MPN must provide access to primary treating physicians within 30 minutes or 15 miles and specialists within 60 minutes or 30 miles of where you work or live.

If you live in a rural area or an area where there is a health care shortage, there may be a different standard.

After you have notified your employer of your injury, the MPN must provide initial treatment within 3 business days. If treatment with a specialist has been authorized, the appointment with the specialist must be provided to you within 20 business days of your request.

mailto:[email protected]://www.nbsiampn.org/http://www.nbsiampn.org/

NBSIA EE Notice as of October 2016

EMPLOYEE ACKNOWLEDGEMENT OF THE MEDICAL PROVIDER NETWORK

RECEIPT – PROOF OF SERVICE

In order to provide the most timely and suitable quality medical care in the event of an injury on the job, we have instituted a Medical Provider Network for Workers’ Compensation. The following procedures must be followed for all work related injuries and illnesses.

Report promptly any work related injury to the supervisor. For a referral to the medical provider specialist, contact your employer or Claims Adjuster. Ensure all medical treatment is handled only through the MPN (Medical Provider Network) unless otherwise

authorized. Direct all questions about the level of care to the PCP (Primary Care Physician), who is the focal point for all medical

treatment. A directory of medical care providers is available at my request through my employer.

Please sign below to indicate that you have read and understand the procedures to follow in the event of an injury and your duties under our Medical Provider Network and have received the following workers’ compensation documents:

Medical Provider Network (MPN) Notice

Employee Name: SS#:

Address:

City, State, Zip:

Date of Hire: Date of Birth:

Signature: Date:

A COPY OF THE MPN DIRECTORY IS AVAILABLE FROM YOUR EMPLOYER OR ADJUSTER UPON YOUR REQUEST. Please keep copy in personnel file.


Employee Information on the Independent Medical Review (IMR) Process

This notice is to inform you or your rights, responsibilities and process in obtaining an Independent Medical Review (IMR). If you disagree with your treatment plan or diagnosis that the third opinion physician rendered, you have the right to request an Independent Medical Review. At the time you request a physician for a third opinion, your MPN contact or Claims Adjuster will provide you with this form covering the Independent Medical Review process. You will also be provided with an “Application for Independent Medical Review” form. The MPN Contact or Claims Adjuster will fill out the “MPN Contact section” for you. You will need to complete the “employee section” of the form, indicate on the form whether you are requesting an in-person examination or a records review. You may also list an alternative specialty, if any, that is different from the specialty of the treating physician. The Administrative Director will select an IMR with an appropriate specialty within ten (10) business days of receiving your Application for Independent Medical Review form. The Administrative Director’s selection of the IMR will be based on the specialty of your treating physician, the alternative specialties listed by you and the MPN contact, and the information submitted with the Application for Independent Medical Review. If you request an in-person examination, the Administrative Director will randomly select a physician from a list of available independent medical reviewers, with an appropriate specialty, who has an office located within thirty (30) miles of your residential address, to be your independent medical reviewer. If there is only one physician with an appropriate specialty within thirty (30) miles of your residential address, that physician shall be selected to the independent medical reviewer. If there are no physicians with an appropriate specialty who have offices located within thirty (30) miles of your residential address, the Administrative Director will search in increasing five (5) mile increments, until one physician is located. If there are no available physicians with this appropriate specialty, the Administrative Director may choose another specialty based on the information submitted. If you request a record review, then the Administrative Director will randomly select a physician with an appropriate specialty from the list of available independent medical reviewers to be the IMR. If there are no physicians with an appropriate specialty, the Administrative Director may choose another specialty based on the information submitted. The Administrative Director will send written notification of the name and contact information of the IMR to you, your attorney, if any, the MPN Contact and the IMR. The Administrative Director will send a copy of the completed Application for Independent Medical Review to the IMR. You, the MPN Contact, or the selected IMR can object within ten (10) calendar days of receipt of the name of the IMR to the selection if there is a conflict of interest as defined by section 9768.2. If the IMR determines that they do not practice the appropriate specialty, the IMR shall withdraw within ten (10) calendar days of receipt of the notification of selection. If the conflict is verified or the IMR withdraws, the Administrative Director will select another IMR from the same specialty. If there are no available physicians with the same specialty, the Administrative Director may select an IMR with another specialty based on the information submitted and in accordance with the procedure set forth for an in-person examination and for a records review. If you request an in-person examination, within sixty (60) calendar days of receiving the name of the IMR, you must contact the IMR to arrange an appointment. If you fail to contact the IMR for an appointment within sixty (60) calendar days of receiving the name of the IMR, then you will be deemed to have waived the IMR process with regard to this disputed diagnosis or treatment of this treating physician. The IMR shall schedule an appointment with you within thirty (30) calendar days of the request for an appointment, unless all parties agree to a later date. The IMR shall notify the MPN contact of the appointment date. Should you decide to withdraw the request for an Independent Medical Review, you need to provide written notice to the Administrative Director and the MPN Contact. During this process, the employee shall remain within the MPN for treatment pursuant to section 9767.6. The MPN Contact shall send all relevant medical records to the IMR. The MPN Contact shall also send a copy of the documents to the covered employee. The employee may furnish any relevant medical records or additional materials to the Independent Medical Reviewer, with a copy to the MPN Contact as set forth in 8 CCR Section 9768.11(a). If you have requested an in-person examination and a special form of transportation is required because of your medical condition, the MPN Contact will arrange it for you. The MPN Contact shall furnish transportation and arrange for an interpreter, if necessary, in advance on the in-person examination. All reasonable expenses of transportation shall be incurred by the insurer or employer pursuant to Labor Code section 4600. Except for the in-person examination itself, the independent medical reviewer shall have no ex parte contact with any party. Except for matters dealing with scheduling appointments,


scheduling medical tests and obtaining medical records, all communications between the independent medical reviewer and any party shall be in writing with copies served on all parties. If the IMR requires further tests, the IMR shall notify the MPN Contact within one (1) working day of the appointment. All tests shall be consistent with the medical treatment utilization schedule adopted pursuant to Labor Code section 5307.27 or, prior to the adoption of this schedule, the ACOEM guidelines, and for all injuries not covered by the medical treatment utilization schedule or the ACOEM guidelines, in accordance with other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based.

PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or medical group if:

• on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated;

• the doctor is your regular physician, who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist, pediatrician,obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, andretains your medical records;

• your “personal physician” may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries;

• prior to the injury your doctor agrees to treat you for work injuries or illnesses;• prior to the injury you provided your employer the following in writing: (1) notice that you want your

personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor's name andbusiness address.

You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met.

NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee: Complete this section.

To: ____________________________ (name of employer) If I have a work-related injury or illness, I choose to be treated by: _________________________________________________________________ (name of doctor)(M.D., D.O., or medical group) _________________________________________________________________ (street address, city, state, ZIP)

__________________________________________________ (telephone number)

Employee Name (please print): _____________________________________________________________________________________________

Employee's Address: _____________________________________________________________________________________________

Name of Insurance Company, Plan, or Fund providing health coverage for nonoccupational injuries or illnesses:

Employee's Signature ________________________________Date: __________

Physician: I agree to this Predesignation:

Signature: _____________________________________________Date: __________ (Physician or Designated Employee of the Physician or Medical Group)

The physician is not required to sign this form, however, if the physician or designated employee of the physician or medical group does not sign, other documentation of the physician's agreement to be predesignated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3).

Title 8, California Code of Regulations, section 9783.

DWC FORM 9783 (7/2014)

OATH OR AFFIRMATION OF ALLEGIANCE

Human Resources

All Personnel E 4112.3 4212.3 4312.3

I, , do solemnly swear (or affirm) that I will support and defend the Constitution of the United States

and the Constitution of the State of California against all enemies, foreign and domestic; that I will

bear true faith and allegiance to the Constitution of the United States and the Constitution of the

State of California; that I take this obligation freely, without any mental reservation or purpose of

evasion; and that I will well and faithfully discharge the duties upon which I am about to enter.

I understand that as a public employee I am a disaster service worker pursuant to Government Code

3100 and 3102 and that I am required to take this oath before entering the duties of my employment.

In the event of natural, manmade or war-caused emergencies which result in conditions of disaster or

extreme peril to life, property or resources, I am subject to disaster services activities to me by my

supervisor.


Certified by:

(Person who administers oath)

Exhibit Version: June 12, 2007

Oath or Affirmation of Allegiance_5.12.16


AUTHORITY FOR RELEASE OF INFORMATION Human Resources

I authorize any hiring official from Travis Unified School District to obtain any information relating to

my employment with past employers listed on my application.

This information may include, but is not limited to, achievement, performance, attendance, personal

history, or disciplinary action.

I direct you to release such information upon request of any designated hiring official from Travis

Unified School District regardless of any agreement I may have made with you previously to the

contrary.

I release the Travis Unified School District and any employee of the district, including records

custodians, from any and all liability for damages that may result to me on account of compliance or

attempts to comply with this authorization.

An electronically transmitted copy or a facsimile of this document constitutes the same as possession

of the original document and signature.

Employee Name (Please Print)


Authority for Release of Information_5.13.16


Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-9 OMB No. 1615-0047

Expires 08/31/2019

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which

document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ

an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in

connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

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

3. A lawful permanent resident (Alien Registration Number/USCIS Number):

4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):

Some aliens may write "N/A" in the expiration date field. (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:

An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

OR

2. Form I-94 Admission Number:

OR

3. Foreign Passport Number:

Country of Issuance:

QR Code - Section 1

Do Not Write In This Space

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my

knowledge the information is true and correct.

Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

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

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

Employer Completes Next Page

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

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

Employee's E-mail Address

- -

Employee's Telephone Number U.S. Social Security Number Date of Birth (mm/dd/yyyy)

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

Other Last Names Used (if any) Middle Initial First Name (Given Name) Last Name (Family Name)

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)

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

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-9 OMB No. 1615-0047

Expires 08/31/2019

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You

must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists

of Acceptable Documents.")

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

List A OR List B AND List C Identity and Employment Authorization Identity Employment Authorization

Document Title Document Title Document Title

Issuing Authority Issuing Authority Issuing Authority

Document Number Document Number Document Number

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

Document Title

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

Document Number

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

Document Title

Issuing Authority

Document Number

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

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,

(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the

employee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

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

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

Travis Unified School District

Employer's Business or Organization Address (Street Number and Name)

2751 De Ronde Dr.

City or Town

Fairfield

State

CA ZIP Code

94533

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) B. Date of Rehire (if applicable)

Last Name (Family Name) First Name (Given Name) Middle Initial Date (mm/dd/yyyy)

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

continuing employment authorization in the space provided below.

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

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if

the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

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

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

LISTS OF ACCEPTABLE DOCUMENTS

All documents must be UNEXPIRED

Employees may present one selection from List A

or a combination of one selection from List B and one selection from List C.

LIST A

Documents that Establish

Both Identity and

Employment Authorization

OR

LIST B LIST C

Documents that Establish Documents that Establish

Identity Employment Authorization

AND

1. U.S. Passport or U.S. Passport Card

1. Driver's license or ID card issued by a

State or outlying possession of the

United States provided it contains a

photograph or information such as

name, date of birth, gender, height, eye

color, and address

1. A Social Security Account Number

card, unless the card includes one of

the following restrictions:

(1) NOT VALID FOR EMPLOYMENT

(2) VALID FOR WORK ONLY WITH

INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH

DHS AUTHORIZATION

2. Permanent Resident Card or Alien

Registration Receipt Card (Form I-551)

3. Foreign passport that contains a

temporary I-551 stamp or temporary

I-551 printed notation on a machine-

readable immigrant visa

2. ID card issued by federal, state or local

government agencies or entities,

provided it contains a photograph or

information such as name, date of birth,

gender, height, eye color, and address

4. Employment Authorization Document

that contains a photograph (Form

I-766)

2. Certification of Birth Abroad issued

by the Department of State (Form

FS-545) 3. School ID card with a photograph

5. For a nonimmigrant alien authorized

to work for a specific employer

because of his or her status:

a. Foreign passport; and

b. Form I-94 or Form I-94A that has

the following:

(1) The same name as the passport;

and

(2) An endorsement of the alien's

nonimmigrant status as long as

that period of endorsement has

not yet expired and the

proposed employment is not in

conflict with any restrictions or

limitations identified on the form.

3. Certification of Report of Birth

issued by the Department of State

(Form DS-1350) 4. Voter's registration card

5. U.S. Military card or draft record 4. Original or certified copy of birth

certificate issued by a State,

county, municipal authority, or

territory of the United States

bearing an official seal

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner

Card

8. Native American tribal document 5. Native American tribal document

9. Driver's license issued by a Canadian

government authority 6. U.S. Citizen ID Card (Form I-197)

7. Identification Card for Use of

Resident Citizen in the United

States (Form I-179)

For persons under age 18 who are

unable to present a document

listed above: 8. Employment authorization

document issued by the

Department of Homeland Security 6. Passport from the Federated States of

Micronesia (FSM) or the Republic of

the Marshall Islands (RMI) with Form

I-94 or Form I-94A indicating

nonimmigrant admission under the

Compact of Free Association Between

the United States and the FSM or RMI

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

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

Refer to the instructions for more information about acceptable receipts.

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

Form W-4 (2019)Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. You may claim exemption from withholding for 2019 if both of the following apply.• For 2018 you had a right to a refund of all federal income tax withheld because you had no tax liability, and• For 2019 you expect a refund of all federal income tax withheld because you expect to have no tax liability.If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2019 expires February 17, 2020. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General InstructionsIf you aren’t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2019 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider

using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income not subject to withholding outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2019. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married filing jointly and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. Nonwage income. If you have a large amount of nonwage income not subject to withholding, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Additional Income Worksheet on page 3 or the calculator at www.irs.gov/W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Specific InstructionsPersonal Allowances WorksheetComplete this worksheet on page 3 first to determine the number of withholding allowances to claim.Line C. Head of household please note: Generally, you may claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.

Line E. Child tax credit. When you file your tax return, you may be eligible to claim a child tax credit for each of your eligible children. To qualify, the child must be under age 17 as of December 31, must be your dependent who lives with you for more than half the year, and must have a valid social security number. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.Line F. Credit for other dependents. When you file your tax return, you may be eligible to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as a qualifying child who doesn’t meet the age or social security number requirement for the child tax credit, or a qualifying relative. To learn more about this credit, see Pub. 972. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total

Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate▶ Whether you’re 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

20191 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 filing separately, check “Married, but withhold at higher Single rate.”

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

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

5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . . 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2019, 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 boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)

9 First date of employment

10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2019)

http://www.irs.gov/FormW4http://www.irs.gov/W4Apphttp://www.irs.gov/http://www.irs.gov/W4App

DE 4 Rev. 46 (12-17) (INTERNET) Page 1 of 4

EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE

1. Number of allowances for Regular Withholding Allowances, Worksheet A

Number of allowances from the Estimated Deductions, Worksheet BTotal Number of Allowances (A + B) when using the CaliforniaWithholding Schedules for 2018

OR2. Additional amount of state income tax to be withheld each pay period (if employer agrees), Worksheet C

OR3. I certify under penalty of perjury that I am not subject to California withholding. I meet the conditions set forth under

the Service Member Civil Relief Act, as amended by the Military Spouses Residency Relief Act. (Check box here) Under the penalties of perjury, I certify that the number of withholding allowances claimed on this certificate does not exceed the number to which I am entitled or, if claiming exemption from withholding, that I am entitled to claim the exempt status.

Signature Date

Employer’s Name and Address California Employer Payroll Tax Account Number

cut here

Give the top portion of this page to your employer and keep the remainder for your records.

YOUR CALIFORNIA PERSONAL INCOME TAX MAY BE UNDERWITHHELD IF YOU DO NOT FILE THIS DE 4 FORM.

IF YOU RELY ON THE FEDERAL FORM W-4 FOR YOUR CALIFORNIA WITHHOLDING ALLOWANCES, YOUR CALIFORNIA STATE PERSONAL INCOME TAX MAY BE UNDERWITHHELD AND YOU MAY OWE MONEY AT THE END OF THE YEAR.

PURPOSE: This certificate, DE 4, is for California Personal Income Tax (PIT) withholding purposes only. The DE 4 is used to compute the amount of taxes to be withheld from your wages, by your employer, to accurately reflect your state tax withholding obligation.

You should complete this form if either:

(1) You claim a different marital status, number of regular allowances,or different additional dollar amount to be withheld for California PITwithholding than you claim for federal income tax withholding or,

(2) You claim additional allowances for estimated deductions.

THIS FORM WILL NOT CHANGE YOUR FEDERAL WITHHOLDING ALLOWANCES.

The federal Form W-4 is applicable for California withholding purposes if you wish to claim the same marital status, number of regular allowances, and/or the same additional dollar amount to be withheld for state and federal purposes. However, federal tax brackets and withholding methods do not reflect state PIT withholding tables. If you rely on the number of withholding allowances you claim on your Form W-4 withholding allowance

City, State, and ZIP Code

Home Address (Number and Street or Rural Route)

Type or Print Your Full Name Your Social Security Number

Filing Status Withholding Allowances

SINGLE or MARRIED (with two or more incomes) MARRIED (one income) HEAD OF HOUSEHOLD

certificate for your state income tax withholding, you may be significantly underwithheld. This is particularly true if your household income is derived from more than one source.

CHECK YOUR WITHHOLDING: After your Form W-4 and/or DE 4 takes effect, compare the state income tax withheld with your estimated total annual tax. For state withholding, use the worksheets on this form.

EXEMPTION FROM WITHHOLDING: If you wish to claim exempt, complete the federal Form W-4. You may claim exempt from withholding California income tax if you did not owe any federal income tax last year and you do not expect to owe any federal income tax this year. The exemption is good for one year. If you continue to qualify for the exempt filing status, a new Form W-4 designating EXEMPT must be submitted by February 15 each year to continue your exemption. If you are not having federal income tax withheld this year but expect to have a tax liability next year, you are required to give your employer a new Form W-4 by December 1.

This form can be used to manually compute your withholding allowances, or you can electronically

compute them at www.taxes.ca.gov/de4.pdf.

CU

https://www.irs.gov/http://www.taxes.ca.gov/de4.pdf

Travis USD AD6

Certificated employee Classified employee Volunteer

N/A

Clarissa Zerzuben

2018w4.pdfGeneral InstructionsDeductions, Adjustments, and Additional Income WorksheetTwo-Earners/Multiple Jobs Worksheet

Instructions for EmployerEmployees, do not complete box 8, 9, or

Activity Supervisor Clearance Certificate.pdfActivity Supervisor Clearance CertificateFingerprint ClearanceApply for a Document

Valid on: undefined: undefined_2: Expiration Date: undefined_3: undefined_4: Valid on_2: undefined_5: undefined_6: Expiration Date_2: undefined_7: undefined_8: Valid on_3: undefined_9: undefined_10: Expiration Date_3: undefined_11: undefined_12: Valid on_4: undefined_13: undefined_14: Expiration Date_4: undefined_15: undefined_16: Positions Applied For 1: Positions Applied For 2: Advertisement: Friend: Relative: Edjoinorg: University Placement Office: Other: Name: Phone: Coaching position applying for: SiteSport: Last Name First Middle: Present Address City Zip: Home Phone Cell Phone: Email Address: SchoolDistrict: PositionSport: Address_2: CityState Zip: Supervisor Name: Telephone Number: Work Performed: Reason for Leaving: NameRow1: OccupationRow1: Phone Email AddressRow1: NameRow2: OccupationRow2: Phone Email AddressRow2: NameRow3: OccupationRow3: Phone Email AddressRow3: Summarize special skills qualifications andor experiences 1: Summarize special skills qualifications andor experiences 2: Name_2: Name of Emergency Contact: Relationship: Mailing Address: State: Zip: Home: Work: Cell: Name of Emergency Contact_2: Relationship_2: Mailing Address_2: City_2: State_2: Zip_2: Home_2: Work_2: Cell_2: Date_2: Person who administers oath: Date_8: Employee Name Please Print: Date_9: Last Name Family Name: First Name Given Name: Middle Initial: Other Last Names Used if any: Address Street Number and Name: Apt Number: City or Town: State_3: ZIP Code: Date of Birth mmddyyyy: US Social Security Number: fill_9: undefined_40: fill_10: undefined_41: Employees Email Address: Employees Telephone Number: 1 A citizen of the United States: 2 A noncitizen national of the United States See instructions: Alien Registration NumberUSCIS Number 1: Alien Registration NumberUSCIS Number 2: QR Code Section 1 Do Not Write In This Space: 1 Alien Registration NumberUSCIS Number: 2 Form I94 Admission Number: 3 Foreign Passport Number: Country of Issuance: Signature of Employee: Todays Date mmddyyyy: Preparer andor Translator Certification check one: A preparers andor translators assisted the employee in completing Section 1: Signature of Preparer or Translator: Todays Date mmddyyyy_2: Last Name Family Name_2: First Name Given Name_2: Address Street Number and Name_2: City or Town_2: State_4: ZIP Code_2: Last Name Family Name_3: First Name Given Name_3: MI: CitizenshipImmigration Status: Document Title: Issuing Authority: Issuing Authority_2: Issuing Authority_3: Document Number: Document Number_2: Document Number_3: Expiration Date if anymmddyyyy: Document Title_2: Issuing Authority_4: Document Number_4: Expiration Date if anymmddyyyy_2: Document Title_3: Issuing Authority_5: Document Number_5: Expiration Date if anymmddyyyy_3: Additional Information: QR Code Sections 2 3 Do Not Write In This Space: See instructions for exemptions: Signature of Employer or Authorized Representative: Todays Datemmddyyyy: Title of Employer or Authorized Representative: Last Name of Employer or Authorized Representative: First Name of Employer or Authorized Representative: City or Town Fairfield: State CA: ZIP Code 94533: A New Name if applicable: B Date of Rehire if applicable: Last Name Family Name_4: First Name Given Name_4: Middle Initial_2: Date mmddyyyy: Document Title_4: Document Number_6: Expiration Date if any mmddyyyy: Signature of Employer or Authorized Representative_2: Todays Date mmddyyyy_3: Name of Employer or Authorized Representative: Check Box2: OffCheck Box3: OffCheck Box4: OffCheck Box5: OffCheck Box6: OffCheck Box7: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box23: OffCheck Box24: OffCheck Box25: OffCheck Box26: OffCheck Box27: OffCheck Box28: OffCheck Box29: OffCheck Box30: OffCheck Box31: OffCheck Box32: OffText34: Check Box35: OffCheck Box36: OffCheck Box37: OffCheck Box38: OffCheck Box39: OffCheck Box40: OffText41: Text42: Text43: Text44: Text45: 4 An alien authorized to work until expiration date if applicable mmddyyyy: 3 A lawful permanent resident: undefined_43: undefined_42: Clear: Group1: OffLast Name: First Name Middle lniUal: AKA or Alias asl: First: Date of Birtn: Dnvers License Number: male: Offfemale: OffHelglU: Weight: Eye Color: Hair Color: Place or Birth State or Country: Social Security Number: Address Street Address or PO Box: City: State ZIP Code: Check Box1: OffFull Name: SSN: Address: City, State, Zip: S: Off1A: 1B: A+B: C: D: OffDate: ER Name & Address: ER Account#: Text1: Text2: Text3: Text4: Text5: Text6: Text7: Text9: Text10: Text11: Text12: Text13: Check Box33: OffCheck Box34: OffCheck Box41: OffText46: Text47: Text49: Text8: Text14: Text15: Text16: Text17: Text18: Check Box42: Off