PERSONNEL COMMISSION APPLICATION UPDATE FOR CLASSIFIED EMPLOYMENT

1. Exact Job Title 2. Social Security Number

3. Last Name First Name Middle Name 4. Have you ever been employed by Long Beach Unified School District? Yes No If Yes, From_______________________ To_____________ 5. Work or Volunteer Experience since original application submitted.

DATE DUTIES EMPLOYER From: ___________ Month/Year To: ___________ Month/Year Hours per Week: ____ Salary: ____________

Hourly Weekly Monthly Volunteer

No. Supervised: _____

Title: _____________________________________ Duties: ___________________________________ _________________________________________ _________________________________________ _________________________________________ Reason for Leaving: Resigned Discharged Other Explain: ____________________________________

___________________________ Name of Present or Last Employer __________________________ Address __________________________ City/State/Zip Code __________________________ Supervisor’s Name __________________________ Telephone

From: ___________ Month/Year To: ___________ Month/Year Hours per Week: ____ Salary: ____________

Hourly Weekly Monthly Volunteer

No. Supervised: _____

Title: _____________________________________ Duties: ___________________________________ _________________________________________ _________________________________________ _________________________________________ Reason for Leaving: Resigned Discharged Other Explain: ____________________________________

___________________________ Name of Present or Last Employer __________________________ Address __________________________ City/State/Zip Code __________________________ Supervisor’s Name __________________________ Telephone

6 List all periods of unemployment since original application was submitted From: _____________ To: _______________ Reason: ___________________________________________ From: _____________ To: _______________ Reason: ___________________________________________ From: _____________ To: _______________ Reason: ___________________________________________

7.Have you ever been discharged or forced to resign from any position because of misconduct or unsatisfactory service?

Yes No If YES, complete the following and attach a sheet explaining the full details. Employer’s Name _________________________ Position Title___________________ Termination Date ________ 8.Do you have a valid California Driver’s License? No Yes Has your license ever been suspended or revoked? No Yes (if Yes, attach a sheet explaining the full details, and attach a copy of your H6 DMV report. 9. CERTIFICATE OF APPLICANT NOTE: Read carefully before signing I HEREBY CERTIFY: That all statements made in this application are true, and I understand and agree that any misstatements or omissions of material facts may cause forfeiture on my part to employment with the Long Beach Unified School District. Signature: ____________________________________ Date: _____________________

Perscomm:Masters: App update – 8/2007

LBUSD PERSONNEL COMMISSION REPORT OF CONVICTIONS AND NOTICE OF FINGERPRINTING FEE

ALL APPLICANTS MUST COMPLETE THIS FORM IN ITS ENTIRETY. THIS FORM WILL BE USED FOR SCREENING PURPOSES AND DISTRICT PROCESSING FOR EMPLOYMENT. IT WILL NOT BE USED IN THE TESTING PROCESS OR AT THE HIRING INTERVIEW. PRINT NAME (LAST, FIRST AND MIDDLE)

SOCIAL SECURITY NO.

Note: Before being considered for employment, all applicants who have prior convictions will be required to provide a certified copy of all relevant records including, but not limited to, conviction reports, probation reports, and other related court records. In accordance with the Board of Education policies and provisions of the Education Code, prior to the employee starting work, all prospective school district employees are fingerprinted, and fingerprints are submitted to the Department of Justice for verification of any information given prior to the employee starting work. Fingerprinting fees of $56 are the financial responsibility of the employee and are collected through equal payroll deductions from the first two payroll checks. If the fingerprint report from the Department of Justice shows convictions that you do not list, you will be disqualified from examination or terminated from employment. FAILURE TO ITEMIZE ALL CONVICTIONS IS CAUSE FOR YOUR DISQUALIFICATION OR DISMISSAL. IF YOU DO NOT FULLY DISCLOSE SUCH INFORMATION ON THIS APPLICATION NOW, IT IS CAUSE FOR REJECTION FOR EMPLOYMENT OR DISMISSAL FROM EMPLOYMENT. PLEASE READ THE FOLLOWING NOTES CAREFULLY: Please list below any and all convictions, including misdemeanors and/or felonies, you received at any time during your lifetime. The term “conviction” includes a plea or verdict of guilty or finding of guilt by a court in a trial without a jury, or a conviction following a plea of nolo contendere. PLEASE NOTE: Expungement or discharge pursuant to Penal Code section 1203.4 does not relieve you of the obligation to answer these questions truthfully when applying for employment with the Long Beach Unified School District. You must include minor traffic violations only if they resulted in the issuance of a warrant for failure to pay fines or appear for sentencing, drunk driving convictions, and convictions following probation. This request does not include any of the following: a. Arrests or detention that did not result in a conviction; b. Referrals to or participation in a pre-trial or post-trial diversion program; c. Any conviction for which the record has been judicially ordered sealed, expunged, or statutorily eradicated (e.g.,

juvenile offense records sealed pursuant to Welfare and Institution Code section 389 and Penal Code sections 851.7 or 1203.45);

d. Any arrest for which a pretrial diversion program has been successfully completed pursuant to Penal Code sections 1000.5 and 1001.5.

HAVE YOU, AS A JUVENILE OR ADULT, EVER BEEN CONVICTED, FINED, IMPRISONED, PLACED ON PROBATION, OR SENTENCED, IN ANY CIVIL, CRIMINAL, OR MILITARY COURT, OR HAVE YOU EVER FORFEITED BAIL? NO YES (Use additional pages if necessary) Name of Offense (Explain in detail on back of this form)

Offense Code #

Date Mo/Yr

Location (City & State)

Misdemeanor or Felony?

If Imprisoned How long?

If Fined $ Amount

If Probation From--- To----

HAS YOUR DRIVER’S LICENSE EVER BEEN SUSPENDED OR REVOKED? NO YES If YES, explain, including when, where it occurred, the outcome, AND attach H6 DMV report.

COMPLETE BACK SIDE OF THIS FORM---

EXPLANATION OF CONVICTION:

Please use this page to write about the offense(s) for which you were convicted. Explain in detail, the incident(s) and thesurrounding circumstances, outcome, etc. Make sure the information you provide matches the convictions on thereverse side of this form.

EXPLANATION OF EVENTS: (You may attach other pages, if necessary):

PLEASE READ BELOW BEFORE SIGNING:

I declare that I have read and understand all of the questions and statements listed on both sides of thisReport of Convictions form and the answers I have given are true, correct, and complete. I understand it ismy responsibility to list any and all convictions, and that anything I may have forgotten or failed to list willresult in rejection for employment or dismissal from employment. I have listed all of my convictions.

HAVE YOU FORGOTTEN SOMETHING? IF YOU HAVE NOT LISTED EVERYTHING, STOP, TURN THIS FORMOVER AND LIST IT NOW!SIGNATURE OF APPLICANT DATE SIGNED

L:\Perscomm\Winword\Masters\LBUSDapplications\conviction 7/22/05

PERSONNEL COMMISSION _____Classified

Classified _____Exempt

EMPLOYEE INFORMATION SHEET Please complete the following demographic information for your personnel file.

Name ______________________________________________ Social Security No. _____________________________ Last First Middle (SS# Verified By_________________)

Were you ever known under any other name? __________________________________________________________ If yes, enter name.

Home/Mailing Address ______________________________________________________________________________ Street or P.O. Box

_________________________________________________________________________________________________ City State Zip County

Telephone ( ) ________________ Cell Phone ( ) ________________ E-Mail Address______________________ Area Code Area Code

Sex: _____M _____F Birthdate____________________ Spouse’s Birthdate____________________

Marital Status: ___Single ___Married ___Divorced ___Widowed Citizenship Code: U.S. Citizen ____Yes ____No

Ethnic Origin: (Please check appropriate origin)

_____I American Indian or Alaskan Native _____H Hispanic – Spanish culture or origin

_____A Asian _____F Filipino – Philippine Islands

_____B Black – not of Hispanic origin _____W White – not of Hispanic origin

_____P Pacific Islander

Are you a veteran of military service? _____Yes _____No

Do you have a physical handicap? _____Yes _____No

If yes, please specify _______________________________________________________________________________ (The District is required to provide statistics to the federal government regarding the number of handicapped persons it employs. This does not affect your employment status.)

EMPLINFO 2013 PC

HUMAN RESOURCE SERVICES 1515 Hughes Way, Long Beach, California 90810 Phone: (562) 997-8208 Fax (562) 997-8298 HRShelp@lbschools.net

Beneficiary Information

In the event of your death, salary or other monies may be owed to you as an employee of our district. The

form below permits immediate release of any warrants (checks) to a person you designate. This can assist in

time of family stress or financial need.

Warrant(s) Recipient Designation

Under the provisions of Section 53245 of the California Government Code, in the event of my death I hereby designate the following named person to be entitled to receive all warrants payable to me by the Long Beach Unified School District had I survived:

No. 1 ___________________________________________________ _______________________ Designee’s Full Name Relationship

_________________________________________________________________________________ Address City State Zip Code

or in the event of death of Designee #1:

No. 2 ____________________________________________________ _______________________ Designee’s Full Name Relationship

__________________________________________________________________________________ Address City State Zip Code

This designation cancels and replaces any previously signed by me for this purpose and shall remain in effect until canceled in writing by me.

It is expressly understood and agreed that the Long Beach Unified School District is not obligated to deliver said warrants to the person designated hereinabove unless said designated person, within two years after the date of said warrant or warrants, claims said warrants from the Long Beach Unified School District and provides to said School District sufficient proof of identity pursuant to the provisions of Section 53245 of the California Government Code.

_________________________________________________ _________________________ Signature Date

_________________________________________________ __________________________ Print Name Social Security Number

Return this form to Human Resource Services

07/09 revision

PERSONNEL COMMISSION 4400 Ladoga Avenue, Lakewood, California 90813 Phone: (562) 435-5708

Acknowledgment of Receipt

Name: _______________________________________________________________

Soc. Sec. Num.: ______________________________________________________________

I acknowledge that I have read and received the following required notices and Board policies. I will follow said requirements during my employment with the Long Beach Unified School District (please initial each section).

______ Mission Statement and Code of Ethics (BP 4119.21)

______ Reporting Suspected Child Abuse and Child Abuse Reporting requirements Section 11166 and Section 11172 (b) of the California Penal Code and will follow said requirements during my employment with the Long Beach Unified School District.

______ Policies on the prohibition of Sexual Harassment (BP 4119.11 – AR 4119.11) (BP 5145.7 – AR 5145.7).

______ Policy on Nondiscrimination in Employment (BP 4030). Initial ______ Policy on Nondiscrimination/Harassment-Students (BP 5145.3). Initial ______ Policy on Drug-Free Workplace (BP 4160).

______ Policy on a Tobacco-Free Workplace (BP 3513.3 – AR 3513.3).

______ Policy on District Internet and Electronic Mail (BP 4040 – AR 4040). Initial ______ Policy on Unauthorized Release of Confidential/Privileged Information (BP 4119.23) Initial _____ Oath of Allegiance for Public Employees or Officers.

“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.

Signature: _________________________________________ Date: ______________

Print name: ________________________________________

Note: This acknowledgment will remain on file in the Human Resource Services office as required by law.

Last First MI

Initial

Initial

Initial

Initial

Initial

Initial

Instructions for Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS Form I-9

OMB No. 1615-0047 Expires 03/31/2016

Read all instructions carefully before completing this form. Anti-Discrimination Notice. It is illegal to discriminate against any work-authorized individual in hiring, discharge, recruitment or referral for a fee, or in the employment eligibility verification (Form I-9 and E-Verify) process based on that individual's citizenship status, immigration status or national origin. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration-Related Unfair Employment Practices (OSC) at 1-800-255-7688 (employees), 1-800-255-8155 (employers), or 1-800-237-2515 (TDD), or visit www.justice.gov/crt/about/osc.

Form I-9 Instructions 03/08/13 N Page 1 of 9EMPLOYERS MUST RETAIN COMPLETED FORM I-9

DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS

What Is the Purpose of This Form?

Form I-9 is made up of three sections. Employers may be fined if the form is not complete. Employers are responsible for retaining completed forms. Do not mail completed forms to U.S. Citizenship and Immigration Services (USCIS) or Immigration and Customs Enforcement (ICE).

Employers are responsible for completing and retaining Form I-9. For the purpose of completing this form, the term "employer" means all employers, including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors.

General Instructions

Section 1. Employee Information and AttestationNewly hired employees must complete and sign Section 1 of Form I-9 no later than the first day of employment. Section 1 should never be completed before the employee has accepted a job offer. Provide the following information to complete Section 1:

Name: Provide your full legal last name, first name, and middle initial. Your last name is your family name or surname. If you have two last names or a hyphenated last name, include both names in the last name field. Your first name is your given name. Your middle initial is the first letter of your second given name, or the first letter of your middle name, if any. Other names used: Provide all other names used, if any (including maiden name). If you have had no other legal names, write "N/A." Address: Provide the address where you currently live, including Street Number and Name, Apartment Number (if applicable), City, State, and Zip Code. Do not provide a post office box address (P.O. Box). Only border commuters from Canada or Mexico may use an international address in this field.

Date of Birth: Provide your date of birth in the mm/dd/yyyy format. For example, January 23, 1950, should be written as 01/23/1950.

Employers must complete Form I-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 6, 1986, to work in the United States. In the Commonwealth of the Northern Mariana Islands (CNMI), employers must complete Form I-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 27, 2011. Employers should have used Form I-9 CNMI between November 28, 2009 and November 27, 2011.

E-mail Address and Telephone Number (Optional): You may provide your e-mail address and telephone number. Department of Homeland Security (DHS) may contact you if DHS learns of a potential mismatch between the information provided and the information in DHS or Social Security Administration (SSA) records. You may write "N/A" if you choose not to provide this information.

U.S. Social Security Number: Provide your 9-digit Social Security number. Providing your Social Security number is voluntary. However, if your employer participates in E-Verify, you must provide your Social Security number.

Form I-9 Instructions 03/08/13 N Page 2 of 9

3. A lawful permanent resident: A lawful permanent resident is any person who is not a U.S. citizen and who residesin the United States under legally recognized and lawfully recorded permanent residence as an immigrant. The term"lawful permanent resident" includes conditional residents. If you check this box, write either your Alien RegistrationNumber (A-Number) or USCIS Number in the field next to your selection. At this time, the USCIS Number is thesame as the A-Number without the "A" prefix.

4. An alien authorized to work: If you are not a citizen or national of the United States or a lawful permanent resident,but are authorized to work in the United States, check this box.

a. Record the date that your employment authorization expires, if any. Aliens whose employment authorization doesnot expire, such as refugees, asylees, and certain citizens of the Federated States of Micronesia, the Republic of theMarshall Islands, or Palau, may write "N/A" on this line.

b. Next, enter your Alien Registration Number (A-Number)/USCIS Number. At this time, the USCIS Number is thesame as your A-Number without the "A" prefix. If you have not received an A-Number/USCIS Number, recordyour Admission Number. You can find your Admission Number on Form I-94, "Arrival-Departure Record," or asdirected by USCIS or U.S. Customs and Border Protection (CBP).

(1) If you obtained your admission number from CBP in connection with your arrival in the United States, thenalso record information about the foreign passport you used to enter the United States (number and country of issuance).

(2) If you obtained your admission number from USCIS within the United States, or you entered the United States without a foreign passport, you must write "N/A" in the Foreign Passport Number and Country of Issuance fields.

Sign your name in the "Signature of Employee" block and record the date you completed and signed Section 1. By signing and dating this form, you attest that the citizenship or immigration status you selected is correct and that you are aware that you may be imprisoned and/or fined for making false statements or using false documentation when completing this form. To fully complete this form, you must present to your employer documentation that establishes your identity and employment authorization. Choose which documents to present from the Lists of Acceptable Documents, found on the last page of this form. You must present this documentation no later than the third day after beginning employment, although you may present the required documentation before this date.

The Preparer and/or Translator Certification must be completed if the employee requires assistance to complete Section 1 (e.g., the employee needs the instructions or responses translated, someone other than the employee fills out the information blocks, or someone with disabilities needs additional assistance). The employee must still sign Section 1.

Minors and Certain Employees with Disabilities (Special Placement)Parents or legal guardians assisting minors (individuals under 18) and certain employees with disabilities should review the guidelines in the Handbook for Employers: Instructions for Completing Form I-9 (M-274) on www.uscis.gov/I-9Central before completing Section 1. These individuals have special procedures for establishing identity if they cannot present an identity document for Form I-9. The special procedures include (1) the parent or legal guardian filling out Section 1 and writing "minor under age 18" or "special placement," whichever applies, in the employee signature block; and (2) the employer writing "minor under age 18" or "special placement" under List B in Section 2.

Preparer and/or Translator Certification

If you check this box:

1. A citizen of the United States2. A noncitizen national of the United States: Noncitizen nationals of the United States are persons born in American

Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizennationals born abroad.

All employees must attest in Section 1, under penalty of perjury, to their citizenship or immigration status by checking one of the following four boxes provided on the form:

Form I-9 Instructions 03/08/13 N Page 3 of 9

2. Record the document title shown on the Lists of Acceptable Documents, issuing authority, document number andexpiration date (if any) from the original document(s) the employee presents. You may write "N/A" in any unusedfields.

3. Under Certification, enter the employee's first day of employment. Temporary staffing agencies may enter the first daythe employee was placed in a job pool. Recruiters and recruiters for a fee do not enter the employee's first day ofemployment.

4. Provide the name and title of the person completing Section 2 in the Signature of Employer or AuthorizedRepresentative field.

5. Sign and date the attestation on the date Section 2 is completed.

6. Record the employer's business name and address.

7. Return the employee's documentation.

If the employee is a student or exchange visitor who presented a foreign passport with a Form I-94, the employershould also enter in Section 2:a. The student's Form I-20 or DS-2019 number (Student and Exchange Visitor Information System-SEVIS Number);

and the program end date from Form I-20 or DS-2019.

Employers or their authorized representative must:1. Physically examine each original document the employee presents to determine if it reasonably appears to be genuine

and to relate to the person presenting it. The person who examines the documents must be the same person who signsSection 2. The examiner of the documents and the employee must both be physically present during the examinationof the employee's documents.

Employers cannot specify which document(s) employees may present from the Lists of Acceptable Documents, found on the last page of Form I-9, to establish identity and employment authorization. Employees must present one selection from List A OR a combination of one selection from List B and one selection from List C. List A contains documents that show both identity and employment authorization. Some List A documents are combination documents. The employee must present combination documents together to be considered a List A document. For example, a foreign passport and a Form I-94 containing an endorsement of the alien's nonimmigrant status must be presented together to be considered a List A document. List B contains documents that show identity only, and List C contains documents that show employment authorization only. If an employee presents a List A document, he or she should not present a List B and List C document, and vice versa. If an employer participates in E-Verify, the List B document must include a photograph.

Employers or their authorized representative must complete Section 2 by examining evidence of identity and employment authorization within 3 business days of the employee's first day of employment. For example, if an employee begins employment on Monday, the employer must complete Section 2 by Thursday of that week. However, if an employer hires an individual for less than 3 business days, Section 2 must be completed no later than the first day of employment. An employer may complete Form I-9 before the first day of employment if the employer has offered the individual a job and the individual has accepted.

In the field below the Section 2 introduction, employers must enter the last name, first name and middle initial, if any, that the employee entered in Section 1. This will help to identify the pages of the form should they get separated.

Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they should be made for ALL new hires or reverifications. Photocopies must be retained and presented with Form I-9 in case of an inspection by DHS or other federal government agency. Employers must always complete Section 2 even if they photocopy an employee's document(s). Making photocopies of an employee's document(s) cannot take the place of completing Form I-9. Employers are still responsible for completing and retaining Form I-9.

Before completing Section 2, employers must ensure that Section 1 is completed properly and on time. Employers may not ask an individual to complete Section 1 before he or she has accepted a job offer.

Section 2. Employer or Authorized Representative Review and Verification

Form I-9 Instructions 03/08/13 N Page 4 of 9

2. Write the word "receipt" and its document number in the "Document Number" field. Record the last day that thereceipt is valid in the "Expiration Date" field.

1. Record the document title in Section 2 under the sections titled List A, List B, or List C, as applicable.

When the employee provides an acceptable receipt, the employer should:

2. Record the number and other required document information from the actual document presented.3. Initial and date the change.

1. Cross out the word "receipt" and any accompanying document number and expiration date.

By the end of the receipt validity period, the employer should:

See the Handbook for Employers: Instructions for Completing Form I-9 (M-274) at www.uscis.gov/I-9Central for more information on receipts.

Employers or their authorized representatives should complete Section 3 when reverifying that an employee is authorized to work. When rehiring an employee within 3 years of the date Form I-9 was originally completed, employers have the option to complete a new Form I-9 or complete Section 3. When completing Section 3 in either a reverification or rehire situation, if the employee's name has changed, record the name change in Block A.

3. The departure portion of Form I-94/I-94A with a refugee admission stamp. The employee must present an unexpiredEmployment Authorization Document (Form I-766) or a combination of a List B document and an unrestricted SocialSecurity card within 90 days.

Section 3. Reverification and Rehires

1. A receipt showing that the employee has applied to replace a document that was lost, stolen or damaged. Theemployee must present the actual document within 90 days from the date of hire.

There are three types of acceptable receipts:

2. The arrival portion of Form I-94/I-94A with a temporary I-551 stamp and a photograph of the individual. Theemployee must present the actual Permanent Resident Card (Form I-551) by the expiration date of the temporaryI-551 stamp, or, if there is no expiration date, within 1 year from the date of issue.

Employees must present receipts within 3 business days of their first day of employment, or in the case of reverification, by the date that reverification is required, and must present valid replacement documents within the time frames described below.

If an employee is unable to present a required document (or documents), the employee can present an acceptable receipt in lieu of a document from the Lists of Acceptable Documents on the last page of this form. Receipts showing that a person has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not acceptable. Employers cannot accept receipts if employment will last less than 3 days. Receipts are acceptable when completing Form I-9 for a new hire or when reverification is required.

Receipts

Generally, only unexpired, original documentation is acceptable. The only exception is that an employee may present a certified copy of a birth certificate. Additionally, in some instances, a document that appears to be expired may be acceptable if the expiration date shown on the face of the document has been extended, such as for individuals with temporary protected status. Refer to the Handbook for Employers: Instructions for Completing Form I-9 (M-274) or I-9 Central (www.uscis.gov/I-9Central) for examples.

Unexpired Documents

For employees who provide an employment authorization expiration date in Section 1, employers must reverify employment authorization on or before the date provided.

Form I-9 Instructions 03/08/13 N Page 5 of 9

b. Record the document title, document number, and expiration date (if any).

3. Complete Block C if:

a. The employment authorization or employment authorization document of a current employee is about to expire andrequires reverification; or

b. You rehire an employee within 3 years of the date this form was originally completed and his or her employmentauthorization or employment authorization document has expired. (Complete Block B for this employee as well.)

To complete Block C:a. Examine either a List A or List C document the employee presents that shows that the employee is currently

authorized to work in the United States; and

2. Complete Block B with the date of rehire if you rehire an employee within 3 years of the date this form was originallycompleted, and the employee is still authorized to be employed on the same basis as previously indicated on this form.Also complete the "Signature of Employer or Authorized Representative" block.

1. Complete Block A if an employee's name has changed at the time you complete Section 3.To complete Section 3, employers should follow these instructions:

For reverification, an employee must present unexpired documentation from either List A or List C showing he or she is still authorized to work. Employers CANNOT require the employee to present a particular document from List A or List C. The employee may choose which document to present.

If both Section 1 and Section 2 indicate expiration dates triggering the reverification requirement, the employer should reverify by the earlier date.

Reverification applies if evidence of employment authorization (List A or List C document) presented in Section 2 expires. However, employers should not reverify: 1. U.S. citizens and noncitizen nationals; or2. Lawful permanent residents who presented a Permanent Resident Card (Form I-551) for Section 2.Reverification does not apply to List B documents.

Some employees may write "N/A" in the space provided for the expiration date in Section 1 if they are aliens whose employment authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau). Reverification does not apply for such employees unless they chose to present evidence of employment authorization in Section 2 that contains an expiration date and requires reverification, such as Form I-766, Employment Authorization Document.

There is no fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the "USCIS Privacy Act Statement" below.

What Is the Filing Fee?

USCIS Forms and InformationFor more detailed information about completing Form I-9, employers and employees should refer to the Handbook for Employers: Instructions for Completing Form I-9 (M-274).

4. After completing block A, B or C, complete the "Signature of Employer or Authorized Representative" block,including the date.For reverification purposes, employers may either complete Section 3 of a new Form I-9 or Section 3 of the previouslycompleted Form I-9. Any new pages of Form I-9 completed during reverification must be attached to the employee'soriginal Form I-9. If you choose to complete Section 3 of a new Form I-9, you may attach just the page containingSection 3, with the employee's name entered at the top of the page, to the employee's original Form I-9. If there is amore current version of Form I-9 at the time of reverification, you must complete Section 3 of that version of the form.

Form I-9 Instructions 03/08/13 N Page 6 of 9

ROUTINE USES: This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The employer will keep this form and make it available for inspection by authorized officials of the Department of Homeland Security, Department of Labor, and Office of Special Counsel for Immigration-Related Unfair Employment Practices.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 35 minutes per response, including the time for reviewing instructions and completing and retaining the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Avenue NW, Washington, DC 20529-2140; OMB No. 1615-0047. Do not mail your completed Form I-9 to this address.

USCIS Privacy Act Statement

AUTHORITIES: The authority for collecting this information is the Immigration Reform and Control Act of 1986, Public Law 99-603 (8 USC 1324a).

PURPOSE: This information is collected by employers to comply with the requirements of the Immigration Reform and Control Act of 1986. This law requires that employers verify the identity and employment authorization of individuals they hire for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States.

DISCLOSURE: Submission of the information required in this form is voluntary. However, failure of the employer to ensure proper completion of this form for each employee may result in the imposition of civil or criminal penalties. In addition, employing individuals knowing that they are unauthorized to work in the United States may subject the employer to civil and/or criminal penalties.

A blank Form I-9 may be reproduced, provided all sides are copied. The instructions and Lists of Acceptable Documents must be available to all employees completing this form. Employers must retain each employee's completed Form I-9 for as long as the individual works for the employer. Employers are required to retain the pages of the form on which the employee and employer enter data. If copies of documentation presented by the employee are made, those copies must also be kept with the form. Once the individual's employment ends, the employer must retain this form for either 3 years after the date of hire or 1 year after the date employment ended, whichever is later.

Photocopying and Retaining Form I-9

Form I-9 may be signed and retained electronically, in compliance with Department of Homeland Security regulations at 8 CFR 274a.2.

Employees with questions about Form I-9 and/or E-Verify can reach the USCIS employee hotline by calling 1-888-897-7781. For TDD (hearing impaired), call 1-877-875-6028.

Information about E-Verify, a free and voluntary program that allows participating employers to electronically verify the employment eligibility of their newly hired employees, can be obtained from the USCIS Web site at www.dhs.gov/E-Verify, by e-mailing USCIS at E-Verify@dhs.gov or by calling 1-888-464-4218. For TDD (hearing impaired), call 1-877-875-6028.

You can also obtain information about Form I-9 from the USCIS Web site at www.uscis.gov/I-9Central, by e-mailing USCIS at I-9Central@dhs.gov, or by calling 1-888-464-4218. For TDD (hearing impaired), call 1-877-875-6028.

To obtain USCIS forms or the Handbook for Employers, you can download them from the USCIS Web site at www.uscis.gov/forms. You may order USCIS forms by calling our toll-free number at 1-800-870-3676. You may also obtain forms and information by contacting the USCIS National Customer Service Center at 1-800-375-5283. For TDD (hearing impaired), call 1-800-767-1833.

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS Form I-9

OMB No. 1615-0047 Expires 03/31/2016

START HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

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.)

Address (Street Number and Name)

E-mail Address Telephone NumberDate of Birth (mm/dd/yyyy)

Other Names Used (if any)

U.S. Social Security Number

Ź

Middle Initial

Apt. Number City or Town State Zip Code

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):

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

Signature of Employee: Date (mm/dd/yyyy):

Date (mm/dd/yyyy):Signature of Preparer or Translator:

Address (Street Number and Name) City or Town Zip CodeState

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

A citizen of the United States A noncitizen national of the United States (See instructions)

1. Alien Registration Number/USCIS Number:

For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR Form I-94 Admission Number:

If you obtained your admission number from CBP in connection with your arrival in the UnitedStates, include the following:

2. Form I-94 Admission Number:

Country of Issuance:

Foreign Passport Number:

(See instructions)

Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions)

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

- -

. Some aliens may write "N/A" in this field.

Page 7 of 9Form I-9 03/08/13 N

Employer Completes Next Page

I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.

Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.)

OR

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

3-D Barcode Do Not Write in This Space

Page 8 of 9Form I-9 03/08/13 N

Employee Last Name, First Name and Middle Initial from Section 1:

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 examine a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents" on the next page of this form. For each document you review, record the following information: document title, issuing authority, document number, and expiration date, if any.)

CertificationI 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.)

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

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

Last Name (Family Name) Employer's Business or Organization NameFirst Name (Given Name)

City or Town Zip CodeState

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

C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee presented that establishes current employment authorization in the space provided below.

B. Date of Rehire (if applicable) (mm/dd/yyyy):

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

Signature of Employer or Authorized Representative: Date (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.

Middle InitialFirst Name (Given Name)Last Name (Family Name)

Issuing Authority: Issuing Authority:

Document Number:

Document Title:Document Title:

Document Number:

Issuing Authority:

List A OR ANDList B List C

Document Number:

Document Title:

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

Document Title:

Issuing Authority:

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

Document Title:

Issuing Authority:

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

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

Identity and Employment Authorization Identity Employment Authorization

Document Number:

Document Number:

Print Name of Employer or Authorized Representative:

3-D Barcode Do Not Write in This Space

Page 9 of 9Form I-9 03/08/13 N

LISTS OF ACCEPTABLE DOCUMENTS

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

For persons under age 18 who are unable to present a document

listed above:

LIST A LIST B LIST C

2. Permanent Resident Card or AlienRegistration Receipt Card (Form I-551)

8. Employment authorizationdocument issued by theDepartment of Homeland Security

1. Driver's license or ID card issued by aState or outlying possession of theUnited States provided it contains aphotograph or information such asname, date of birth, gender, height, eyecolor, and address

1. A Social Security Account Numbercard, unless the card includes one ofthe following restrictions:

9. Driver's license issued by a Canadiangovernment authority

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

2. Certification of Birth Abroad issuedby the Department of State (FormFS-545)

3. Foreign passport that contains atemporary I-551 stamp or temporaryI-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Documentthat contains a photograph (FormI-766)

3. Certification of Report of Birthissued by the Department of State(Form DS-1350)

3. School ID card with a photograph5. For a nonimmigrant alien authorized

to work for a specific employerbecause of his or her status:

6. Military dependent's ID card4. Original or certified copy of birth

certificate issued by a State,county, municipal authority, orterritory of the United Statesbearing an official seal

7. U.S. Coast Guard Merchant MarinerCard

5. Native American tribal document8. Native American tribal document

7. Identification Card for Use ofResident Citizen in the UnitedStates (Form I-179)

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or localgovernment agencies or entities,provided it contains a photograph orinformation such as name, date of birth,gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Both Identity and

Employment Authorization

Documents that Establish Identity

Documents that Establish Employment Authorization

OR AND

All documents must be UNEXPIRED

6. Passport from the Federated States ofMicronesia (FSM) or the Republic ofthe Marshall Islands (RMI) with FormI-94 or Form I-94A indicatingnonimmigrant admission under theCompact of Free Association Betweenthe United States and the FSM or RMI

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

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

a. Foreign passport; and

(2) VALID FOR WORK ONLY WITHINS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review and Verification," for more information about acceptable receipts.

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

Personnel Commission

Fingerprint Transmittal Form

Agency Identifiers Code: A0333

App Title: _________________________________________________Agency Mail Code: 06070

Applicant Name: _________________________________________________________________ Last First Middle Suffix

DOB: ____________

State of Birth: _____________________________ City: _______________________________

Country of Citizenship: _____________________ Documented: Yes No

Sex: M F __________ __________ ______ ______ Eye Color Hair Color Height Weight

Social Security Number: __________________ CA Driver’s Lic.#: ________________

(AKA) Other Names Used: _________________________________________________________ Last First Middle

Billing#: 110197 Misc.#: ___________________________________________________ (CA ID, Alien Card#, Passport or out of state ID)

Applicant Home Address: ________________________________ City: ____________________

State: _________________ Zip Code: _____________ Telephone# ( )_______________

I certify that the above information is true and correct:

_________________________________________________ _________________________ Applicant Signature Date

For District Use Only

Staff initials: Date: DOJ & FBI

ATI#: Resubmit:

PERSONNEL COMMISSION CORE VALUES Integrity – Respect – Effective Communication – Commitment to Excellence – Compassion – Teamwork

PERSONNEL COMMISSION “Supporting student achievement through quality service.”

April 9, 2012

TO: Regular, Limited Term, Substitute and Exempt Employment Candidates

SUBJECT: DOJ/FBI EMPLOYMENT FINGERPRINT PROCESSING FEE AUTHORIZATION

Congratulations on your tentative offer of employment with the Long Beach Unified School District Classified and/or Exempt Services!

California Education Code section 45125 requires State educational institutions to fingerprint candidates after a conditional offer of employment is made and prior to starting work. This Education Code section also allows for the District to charge candidates for fingerprinting costs. Fingerprint processing fees currently are $49.00 For your convenience, this amount will be deducted in two equal payments from your first two salary warrants.

By signing this form I acknowledge and authorize the Long Beach Unified School District to deduct the cost of employment fingerprinting from my pay warrants.

_______________________________ _____________________________ Print Name SS #

_______________________________ ______________________________ Signature Date

Do Not Write Below This Line

___________________________________________ Prepared By (staff member signature)

DISTRIBUTION: Employee Payroll HRS/employee file

HUMAN RESOURCE SERVICES 1515 Hughes Way, Long Beach, California 90810 (562) 997-8204 Fax (562) 997-8298

School Year: 2015 - 2016

To: New Hire Limited Term Employee

NOTIFICATION OF REASONABLE ASSURANCE

You are hereby notified that you have reasonable assurance of working for us in the 2015- 16 school year as a limited term employee. You also have reasonable assurance of returning to work in the same capacity at the close of all holiday and recess periods during that year. Your services will not be needed during the 2016 summer recess period, unless you are notified by Human Resource Services or Personnel Commission, in writing or by telephone.

We expect to contact and offer you assignments for the following year in the same manner as long as you meet the minimum qualifications. We are making this offer to you based upon the district’s continuing need for limited term employees as demonstrated in prior years and we consider you a vital link in our educational organization. Please be advised that compensation for these assignments will be at the regular rates in effect for this district.

The official mailing address provided below should be given to the Employment Development Department when filing a claim for unemployment insurance benefits:

Long Beach Unified School District c/o TALX

Post Office Box 23020 Oakland, CA 94623-2302

Thank you for joining the Long Beach Unified School District team as a limited term employee.

My signature indicates that I have received a copy of Reasonable Assurance notification:

______________________________________ ______________ Signature Date

Print Name ____________________________

N:\WinWord\ASSURANCE\2015 RA ltrs\201 New Hire LTEs.doc

LONG BEACH UNIFIED SCHOOL DISTRICT STATEMENT OF EMPLOYEE’S PRE-DESIGNATED PHYSICIAN AND EMPLOYEE CONSENT

BD 861 (January 2005)

Page 1 of 2

District Information Form Instructions Long Beach Unified School District Section I: Employee - print name, SSN, work site Business Department – Financial Services and work telephone number Risk Management Branch Section II: Physician - print name, clinic address and Workers’ Compensation Office telephone number. Physician’s signature is 1515 Hughes Way required for processing. Long Beach, CA 90810 Section III: Employee signature and date required. Return Telephone: (562) 997-8231 form to the District’s Workers’ Compensation Office. Telephone: (562) 997-8235 Section IV: District approval is required. Fax: (562) 997-8052

SECTION I ADMINISTRATIVE (Employee)

EMPLOYEE NAME (Print)

EMPLOYEE SSN or ID No.:

WORK SITE (Print)

WORK/TELEPHONE

SECTION II PHYSICIAN’S STATEMENT (Physician)

I have directed the medical treatment for the above listed individual in the past and retain the medical records and medical history for this individual. Furthermore, I understand my obligation to provide all necessary and reasonable medical treatment to this individual in the event of an on-the-job injury or illness sustained by the individual while employed with the Long Beach Unified School District per the Administrative Director’s rules and regulations as stated in Section 9785, Duties of the Primary Treating Physician.

Pursuant to Section 4600 (d) (5) of the Labor Code, the District may require prior authorization of any non-emergency treatment or diagnostic service and may conduct reasonably necessary utilization review pursuant to Section 4610.

PHYSICIAN NAME (Print)

PHYSICIAN SIGNATURE (Sign)

CLINIC ADDRESS (Print)

CLINIC TELEPHONE

SECTION III EMPLOYEE CONSENT (Employee)

Per section 4600 (d) (2) of the Labor Code, an employee may pre-designate his or her personal physician provided: A. The physician is the employee’s regular physician and surgeon, licensed pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code. B. The physician is the employee’s primary care physician and has previously directed the medical treatment of the employee, and who retains the employee’s medical records, including his or her medical history. C. The physician agrees to be pre-designated. I hereby request that I be treated by my personal physician, as listed above, in the event of any occupational injury or illness.

EMPLOYEE SIGNATURE (Sign)

DATE SIGNED

SECTION IV DISTRICT VERIFICATION (Risk Management Branch – Workers’ Compensation Office)

RECEIVED BY: DATE RECEIVED

LONG BEACH UNIFIED SCHOOL DISTRICT STATEMENT OF EMPLOYEE’S PRE-DESIGNATED PHYSICIAN AND EMPLOYEE CONSENT

BD 861 (July 2008)

Page 2 of 2

SECTION III: INSTRUCTIONS AND INFORMATION FOR EMPLOYEES

Should you become ill or injured on the job, you are entitled to first aid or emergency medical treatment, as necessary. Emergency medical treatment is that medical treatment reasonably required by an injured employee immediately following an occupational injury or illness which, if delayed, could decrease the likelihood of maximum recovery.

You shall report all occupational injuries or illnesses to your onsite supervisor. In the event that the injury or illness requires medical treatment beyond “first aid” or results in “lost time” beyond the date of injury, the District must provide you with the Workers’ Compensation Claim Form (DWC 1). “First aid” means any one-time treatment, and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, etc., which do not ordinarily require medical care. Such one-time treatment and follow-up visit for the purpose of observation, is considered first aid, even though provided by a physician or registered professional personnel. “Lost time” means absence from work for a full day or shift beyond the date of injury or illness. You should have received DWC Form 1 at the time you reported the injury to your supervisor. If you did not receive this form or if the injury or illness subsequently requires medical treatment beyond first aid or results in lost time, please telephone the District Workers’ Compensation Office. A Workers’ Compensation Claim Form (DWC 1) will be immediately mailed to your home of residence.

If you have not pre-designated your personal physician in writing prior to the date of this occupational injury or illness, then your medical treatment will be directed by a physician and facility authorized by the District. Within the first thirty (30) days following the date the occupational injury or illness was first reported, you may request an alternate physician from the Third Party Administrator and the request shall be honored within five (5) days. After thirty (30) days from the date the occupational injury or illness was first reported, you may change your treating physician to one of your own choosing by notifying, in writing or by telephone, the District Workers’ Compensation Office or Third Party Administrator only if the District has not established a Medical Provider Network.

If you have pre-designated your personal physician prior to the date of this occupational injury or illness, then your initial medical treatment may be directed by your personal physician or you may report for treatment at the appropriate authorized District location. For the purpose of utilizing an employee-selected physician, initial medical treatment does not include first aid or emergency medical treatment.

SECTION IV: INSTRUCTIONS AND INFORMATION FOR PHYSICIANS

CAUTION: If you are the employee’s personal physician who undertakes to provide treatment pursuant to Labor Code Section 4600 for occupational injuries and illnesses, you must follow all of the filing, reporting, and time requirements specified in the Administrative Director’s rules, Section 9785, Reporting Duties of the Primary Treating Physician.

The Long Beach Unified School District is a self-insured employer with Third Party Administrator (TPA). Within three (3) working days after undertaking to provide initial treatment, you must notify the TPA of the name and address of the treating physician or facility, unless already listed as a District authorized health care facility. Within five (5) working days of your initial examination for every occupational injury or illness, you must send two (2) copies of the completed State of California Form 5021, Doctor’s First Report of Occupational Injury or Illness; one copy to the District and one copy to the TPA. Where the employee has been exposed to bloodborne pathogens, regulated carcinogens, or toxic substances, you are required to provide the District and TPA with your written opinion in accordance with any applicable Section of Title 8, California Code of Regulations for the specific substance within fifteen (15) days of your completed evaluation. Send all required reports and correspondence to the District and TPA. For timely payment, you may send invoices directly to the TPA.

DISTRICT THIRD PARTY ADMINISTRATOR (TPA)LONG BEACH UNIFIED SCHOOL DISTRICT� TRISTAR RISK MANAGEMENT�1515 HUGHES WAY�� P.O. BOX 512028LONG BEACH, CA 90810�� LOS ANGELES, CA 90051ATTN: WORKERS' COMPENSATION OFFICE� TELEPHONE: (562) 506-0300�TELEPHONE: (562) 997-8231�� FAX: (562) 981-0804FAX: (562) 997-8052�����

CAUTION: Failure to file any of the required reports may result in assessment of a civil penalty.

PERS-CASD-801 (12/12)

EMPLOYEE INSTRUCTIONS

1. The Member Reciprocal Self-Certification Form will assist your employer in determining whetheryou are considered a new member or a classic member under PEPRA.

2. As the new employee, you must complete, sign and date the Member Reciprocal Self-CertificationForm to self-certify your most recent service in a reciprocal California Public Retirement System,your first membership date in any previous California Public Retirement System and yourpermanent separation date from the most recent California Public Retirement System; or indicatethat you are not a member of any California Public Retirement System that is subject toReciprocity.

3. As the new employee, you must return the Member Reciprocal Self-Certification Form to yourPersonnel Office within 10 business days of employment.

4. The completion of the Member Reciprocal Self-Certification Form does not establish reciprocityand is not a request to establish reciprocity. In order to request that reciprocity be established,visit the CalPERS web-site at: www.calpers.ca.gov and download the publication: “When YouChange Retirement Systems”, PUB-16. It is the responsibility of the employee to completeand send the “Election to Coordinate Retirement When Changing Retirement Systems,”PERS-MSD-255 Form to CalPERS.

Reciprocal 1937 Act Counties Reciprocal Public Agencies

Alameda Sacramento *City of ConcordContra Costa San Bernardino *City of Costa Mesa (Safety employees only)Fresno San Diego City of Fresno (Miscellaneous andImperial San Joaquin Safety Retirement Systems)Kern San Mateo City of Los Angeles (non-Safety only)Los Angeles Santa Barbara City of Oakland (non-Safety Marin Sonoma employees only)Mendocino Stanislaus City of Pasadena (Fire and PoliceMerced Tulare Retirement System)Orange Ventura *City of Sacramento

*City of San Clemente (non-Safetyemployees only)

Non-Reciprocal & UCRS Retirement Systems City of San Diego*City and County of San Francisco

Non-reciprocal systems are not covered by City of San Josereciprocity retirement laws, but participate Contra Costa Water Districtin retirement agreements with other systems. County of San Luis Obispo

East Bay Municipal Utility DistrictState Teachers’ Retirement System East Bay Regional Park DistrictLegislators’ Retirement System (Safety employees only)Judges’ Retirement System Los Angeles County MetropolitanJudges’ Retirement System II Transportation AuthorityUniversity of California Retirement System (Non-Contract Employees’ Retirement

Income Plan, formerly SouthernCalifornia Rapid Transit District)

*Also CalPERS-covered agency

California Public Employees’ Retirement SystemCustomer Account Services DivisionRetirement Account Services Section

P.O. Box 942709Sacramento, CA 94229-2709TTY: (877) 249-7442888 CalPERS (or 888-225-7377) phone • (916) 795-4166 fax

www.calpers.ca.gov

PERS-CASD-801 (12/12)

MEMBER RECIPROCAL SELF-CERTIFICATION FORMComplete the following information and return this form to your Personnel Office within 10 business days:

EMPLOYEE NAME: ______________________________________________________________________ (Last) (First) (Middle)

SOCIAL SECURITY NUMBER OR CalPERS ID NUMBER: ______________________________________

NAME OF MOST RECENT RECIPROCAL RETIREMENT SYSTEM: _______________________________

PERMANENT SEPARATION DATE FROM MOST RECENT RECIPROCAL RETIREMENT SYSTEM: ____________________________________________________________________________________________

FIRST MEMBERSHIP DATE IN ANY PRIOR CALIFORNIA PUBLIC RETIREMENT SYSTEM THAT IS SUBJECT TO RECIPROCITY: ______________________________________________________________

(Check the applicable statement)

_____ I have not been a member of another California Public Retirement System within the last six months.

_____ I was a member and am retired from the _______________________________ Retirement System and subsequently became employed by a CalPERS-covered employer.

_____ I was a member of the _____________________________ Retirement System and became employed by a CalPERS-covered employer within six months after separating from employment with the previousreciprocal retirement system.

I understand that by accepting employment in a specific retirement system, I am subject to the applicable laws and regulations of that system. I also understand that completing this form does not constitute a request to establish reciprocity. I must complete and return the “Election to Coordinate Retirement When Changing Retirement Systems,” (PERS-MSD-255) Form to CalPERS.

I hereby certify that the foregoing information is true and correct and any information found to be incorrect may require corrections to my account in the California Public Employees’ Retirement System including, but not limited to, my date of membership. CalPERS may make any necessary corrections to my account to ensure I am properlyenrolled and eligible to receive the correct retirement benefits.

______________________________________________ ______________________________SIGNATURE OF EMPLOYEE DATE

TO BE COMPLETED BY EMPLOYER ONLY:

NAME OF CalPERS AGENCY: CalPERS BUSINESS PARTNER ID:

______________________________________________ _______________________________________

CalPERS MEMBERSHIP ELIGIBILITY DATE ORIGINAL HIRE DATE WITH YOUR AGENCY:WITH YOUR AGENCY:

______________________________________________ _______________________________________

DATE MEMBER RECIPROCAL SELF-CERTIFICATION FORM GIVEN TO EMPLOYEE: ________________DATE MEMBER RECIPROCAL SELF-CERTIFICATION FORM RECEIVED FROM EMPLOYEE: __________

______________________________________ _________________ _____________(Please Print) DESIGNEE OF EMPLOYER TITLE DATE

________________________________________________________________________________________DESIGNEE’S SIGNATURE

PERS-CASD-801 (12/12)

MEMBER RECIPROCAL SELF-CERTIFICATION FORMInstructions

Reciprocity is an agreement among public retirement systems to allow members to separate from onepublic employer and enter into employment with another public employer within a specific time limitwithout losing some valuable retirement and related benefit rights.

The Public Employees’ Pension Reform Act of 2013 (PEPRA), effective January 1, 2013, requires a CalPERS covered employer to determine the applicable PEPRA retirement benefit formula for new employees. CalPERS refers to all members that do not fit within the PEPRA definition of a “new member1” as “classic members” who are subject to the Public Employees’ Retirement Law (PERL).PEPRA allows a member after January 1, 2013, to retain his/her classic member retirement benefitstatus if the member continues his/her membership in all previous California Public Retirement System(s) by leaving his/her service credit and contributions (if any) on deposit, and the memberenters into employment that results in CalPERS membership within six months of separating from the most recent California Public Retirement System. Classic member status also requires the membership date to be on or before December 31, 2012, in a California Public Retirement System in which reciprocity is established.

EMPLOYER INSTRUCTIONS

1. Employers must provide the Member Reciprocal Self-Certification Form to all new employeesupon eligibility for membership.

2. Employers must sign and date the Member Reciprocal Self-Certification Form on the date the formis given to the employee.

3. Upon receipt of the completed Member Reciprocal Self-Certification Form, the employer will enterthe date the employee returns the form.

4. The employer will enroll the new employee into CalPERS membership through my|CalPERSbased on the information provided on the Member Reciprocal Self-Certification Form.my|CalPERS will determine the proper retirement benefit formula. If an employer believes theretirement benefit formula is incorrect, employers may contact CalPERS at 1-888-225-7377.

5. It is the responsibility of the employer to retain the completed Member Reciprocal Self-CertificationForm in the employee’s employment records for auditing purposes.

1A new member is defined in PEPRA as any of the following:• A new hire who is brought into CalPERS membership for the first time on or after January 1, 2013, who has

no prior membership in any California Public Retirement System.• A new hire who is brought into CalPERS membership for the first time on or after January 1, 2013, who has

a break in service of greater than six months with another California Public Retirement System that issubject to Reciprocity.

• A member who first established CalPERS membership prior to January 1, 2013, who is rehired by adifferent CalPERS employer after a break in service of greater than six months.

LONG BEACH UNIFIED SCHOOL DISTRICT, 1515 Hughes Way, Long Beach, CA 90810 Employer's Federal ID# 95-6001886

EMPLOYEE'S WITHHOLDING ALLOWANCE CERTIFICATE State ID# 800-9069-9

FORM Federal and State (This certificate is for income tax withholding purposes only.)

Type or print your Full Name: Social Security NumberLast First M.I.

Home Address:

(Number & Street or rural route ) FEDERAL

MARITAL STATUSSTATE

MARITAL STATUS City or Town State Zip Single Married Single Married

Married but withhold at Single Rate

Head of Household

1. Total number of regular allowances you are claiming.2. Total number of allowances for itemized deductions (State only)3. Total number of allowances (Add line 1 and 2 for State only)4. Additional amount, if any, you want deducted from each pay period. $ $

5. I claim exemption from withholding because:

Signature Date Rev. 10/12

If married but legally separated or spouse is a nonresident alien; check the single boxes below.

a. Last year I did not owe any Federal/State income tax and had a right toa full refund of ALL income tax withheld AND

b. This year I do not expect to owe any Federal/State income tax andexpect to have a full refund of ALL income tax withheld. If both a and b apply, enter EXEMPT.

Under the penalties of perjury, I certify that I am entitled to the number of withholding allowances claimed on this certificate, or if claiming exemption from withholding that I am entitled to claim exempt status.

W4

DIRECT DEPOSIT AUTHORIZATION New Change Cancel

Name: Soc. Sec. No.: Site. Ext.: Attached is a void check showing the institution routing # and account number of the following account: Name of Banking Institution Branch Account Number Checking Savings Address I hereby authorize the Long Beach Unified School District and the Los Angeles County Office of Education and their agents, to initiate electronic deposit, and, as necessary debit corrections to previous deposits, to the listed account. Direct deposit is not activated until 20 days following a $0 test transaction. A new authorization form must be submitted if I change my account (institution, branch, name, etc.). It will take 20 days to be re-activated in direct deposit following any change. Automatic deposit status may be temporarily suspended if wages are garnished. This authorization replaces any previously made by me and is to remain in effect until changed or cancelled by submission of a new Authorization form or upon termination of employment. Once direct deposit has been activated, all check stubs will be sent to my current mailing address. Signature: Date:

DISTRICT USE ONLY

Financial Routing Number Account Number C/S Input by: Date:

W A R R A N T L O C A T I O N F O R M

LAST NAME M/I

(Select only ONE of the following) NOTE: All regular employees MUST use site location

Pay location No. and name

999 Mailing Address

Date

BD-192 Rev. 10/12

Enployee Signature (Use payroll name)

FIRST NAME

E-EMPLOYEE ID NO.

Designation of Beneficiary Form Public Agency Retirement Services (PARS)

Instructions: 1. Read carefully the rules for designating a beneficiary below, and sign in the spaces provided.2. Complete the appropriate sections (Section 1 must be completed, see rules below regarding section 2) of this

form and return it to:Long Beach Unified School District

1515 Hughes Way Long Beach, CA 90810

Rules for Designation of Beneficiary: 1. It is your responsibility to keep your Designation of Beneficiary current.2. You reserve the right to revoke or change your Designation of Beneficiary, subject to the other provisions of

these Rules.3. If, upon your death, there is no valid Designation of Beneficiary on file with the Trust Administrator, any death

benefits which become due will be paid in accordance with the Plan Document.4. The plan requires that if you are married, your surviving spouse/registered domestic partner will be your sole

primary beneficiary, unless your spouse/registered domestic partner waives this right.5. If you wish to designate a person or persons other than your spouse/registered domestic partner or in addition to

your spouse/registered domestic partner, you must obtain the notarized consent of your spouse/registereddomestic partner in writing on this form by completing Section 2. Failure to obtain your spouse/registereddomestic partner’s consent in these instances will render the designation invalid. Any consent by aspouse/registered domestic partner applies only to that spouse/registered domestic partner and not any futurespouse/registered domestic partner. Therefore, if a new marriage occurs, a new Designation of Beneficiary formshould be completed and the new spouse/registered domestic partner’s consent must be obtained. If you areunmarried complete Section 1 only.

6. If the location of your spouse/registered domestic partner is unknown, you must attach to this form a notarizedstatement stating that your spouse/registered domestic partner cannot be located.

7. You are considered married if you are under decree of separate maintenance or decree of legal separation.8. If you wish to have your PARS account distributed under the terms of a Living Trust, your PARS account must be

mentioned by name in the Trust Document. If your current Living Trust does not contain specific reference toyour PARS account, you may designate the Living Trust as a beneficiary using this form. All rules pertaining tothe designation of a beneficiary apply to the designation of a Living Trust.

I have read and understand these rules.

Participant’s Signature Date

Section 1: Designating a Beneficiary Participant Name: Social Security # - -

Participant Address:

City : State: Zip: Phone #:

Name of Beneficiary: Relationship:

Beneficiary Address:

City: State: Zip: Phone:

Participant’s Signature Date Section 2: Spousal/Registered Domestic Partner Consent (Do not complete this section if you are unmarried or do not have a Registered Domestic Partner)

I hereby consent to the above beneficiary designation of my spouse/registered domestic partner, a participant in this plan. I understand that in consenting to the designation of anyone except myself, I am waiving rights to a survivor benefit that I would be legally entitled to at a later date.

Spouse/Registered Domestic Partner’s Signature Date

Signature of Notary Date

Classified Substitute Employee Availability

Name_____________________________________________________________________________

Current Phone # ( )_______________________ Classification ___________________________

Address __________________________________________________________________________ Street Apt #

_________________________________________________________________________________ City State Zip Code

I am available to substitute as follows:

Monday _____ No _____ Yes, from _____ a.m. to _____ p.m.

Tuesday _____ No _____ Yes, from _____ a.m. to _____ p.m.

Wednesday _____ No _____ Yes, from _____ a.m. to _____ p.m.

Thursday _____ No _____ Yes, from _____ a.m. to _____ p.m.

Friday _____ No _____ Yes, from _____ a.m. to _____ p.m.

Comments: _______________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Signature ____________________________________________ Date ________________________

FOR OFFICE USE ONLY

Effective Date _____________ Board Action Date______________ TB Test Date ____________

PERSONNEL COMMISSION

CLASSIFIED SERVICE TEMPORARY WORK INFORMATION

POSITION: _______________________________________________________________________

I, ______________________________, understand the following: (paragraphs applicable are checked)(Print Name)

√ SUBSTITUTE ASSIGNMENT. I understand that I have accepted an appointment as anongoing substitute. My assignment may continue in force in a single assignment, or in variousassignments, but will not in itself lead to a permanent appointment. I must first be assigned toand serve in a regular probationary appointment before permanency is accorded me. This isnot such an appointment.

_____ PROVISIONAL ASSIGNMENT. I understand that I am being appointed without having completed the testing requirements under the Merit (Civil Service) System of the Personnel Commission. Under the Terms of a provisional assignment I can only work an absolute maximum of ninety (90) working days and then I must be laid off. I also understand that if an eligibility list is created in the meantime I must be laid off from my provisional assignment within 15 days after that list is created. Candidates who successfully pass the exam are eligible to be converted from provisional to LTE and/or substitute status.

√ I understand that accepting this temporary work does NOT necessarily entitle me to a regularjob or enhance the possibility of gaining any permanency with the Long Beach Unified SchoolDistrict.

√ I understand I must be in the top three ranks of candidates (based on final score) available andeligible for appointment on an effective eligibility list at the time a job is open or vacant inorder to be considered for a particular job, even though it may be the one I am being employedin now, or appears to be the same one.

√ I understand that it is my responsibility to keep my eligibility current on a list, and to keep thePersonnel Commission Office advised of my current phone number and address or any changeswhen they occur.

√ I understand that no one except the Executive Officer, Personnel Commission or his/herdesignated staff has the authority to offer me or promise me any kind of job within thisdistrict. I understand I do not have to give or promise anyone any money, or any services orfavors in order to get a job. All jobs are obtained through competitive examinations and byappointment from an eligibility list.

Signature: ________________________________________ Date: _______________________

c: Personnel File, Personnel Commission, Employee

PRCPC09\Forms\tempworkinfo (Revised 3/07)

HUMAN RESOURCE SERVICES Employment Physician Services

Post-Offer Work Fitness Medical Questionnaire

Name: (Last)

(First) (M.I.) Date of Birth Today’s Date:

Address: Phone Number: SSN:

Job Position:

Person to Notify in Emergency: Phone Number:

Please complete this post-offer medical questionnaire in your own writing. Misrepresentation or deliberate omission of relevant information may be grounds for denying employment or termination. All yes answers should be fully explained in the comments section of this form. Please note: This is not a diagnostic examination. The purpose of this questionnaire is to determine your fitness to perform specific job tasks with or without accommodations and to ensure the safety of yourself and others.

Your work assignment requires particular visual, hearing and speech abilities. Do you have any impairment of:

Yes No Vision in either eye that interferes with your ability to read, see at a distance, distinguish colors, or see in a dim light?

Yes No Hearing that interferes with your ability to understand spoken words, requires you to wear a hearing aid or requires you to avoid exposure to excessive noise?

Yes No Speech that interferes with your ability to communicate by means of your voice?

Your work assignment requires abilities to maintain a firm grip, to lift and carry bulky or heavy objects, to stand, walk and climb on irregular work surfaces, ladders, and scaffolding. Some work assignments may require frequent and prolonged bending of the neck and back, while others require repetitive use of the upper or lower extremities. As a result of injury, illness or other cause, do you have any impairment of:

Yes No Either arm or shoulder that limits normal range of motion, full use, or strength of your upper extremities?

Yes No Either hand that limits dexterity or your ability to maintain a strong grip or hold objects firmly?

Yes No Either foot knee or leg which limits normal range of motion or your ability to stand, walk, squat, kneel, climb stairs, work on ladders or scaffolding, or walk about on slippery or uneven work surfaces?

Yes No The neck which interferes with bending or rotation of your neck or which interferes with your ability to hold your head in a fixed position for prolonged periods of time?

Yes No The back which interferes with your ability to bend your back frequently or your ability to lift and carry heavy objects?

Certain work assignments can aggravate or promote the spread of infectious disease. In addition, unsafe work behavior may result from certain types of mental illness. Considering this, carefully answer the following questions:

Yes No At the present time do you have active tuberculosis, hepatitis or any other form of contagious disease? Yes No Are you currently being treated, or have you been treated, for an emotional disorder or psychiatric condition within the past four (4) years? Complete for Non-Clerical Classified positions and Science teachers only:

2014 - 2015

Your assignment involves exposure to noise, chemicals and various forms of radiation. An individual’s history of exposure and tolerance to these agents must be considered before new assignments are made. Considering this, carefully answer the following questions. Have you ever:

Yes No Been poisoned by chemicals, gases, fumes, metal, etc.?

Yes No Become allergic to any chemicals with which you have worked?

Yes No Had periodic physical examinations because of exposure to hazardous materials?

Yes No Left a job or changed your occupation because your work involved exposure to noise, chemical or radiation?

Yes No Worked in a job that was noisy, made your ears ring, or made it hard for you to hear?

Yes No Been told to limit or restrict your work activities because of exposure to noise, chemicals or radiation?

Complete for Non-Clerical Classified positions only:

Some job assignments could be extremely dangerous in the event of dizziness, loss of consciousness or loss of equilibrium. As a result of injury or illness do you have any impairment which may:

Yes No Affect your equilibrium or ability to maintain balance?

Yes No Alter your normal state of consciousness or cause you to become unconscious?

Yes No Make it dangerous for you to work at unguarded hazardous heights or around moving machinery?

Yes No Prohibit you from driving licensed company vehicles on public highways?

Yes No Prohibit you from working alone in remote, isolated or confined spaces?

Yes No Limit your ability to perform very strenuous physical activity? Complete for Non-Clerical Classified positions and Science teachers only:

Your assignment requires work with potential allergens and skin irritants such as solvents, fiberglass, resins or other chemicals. Work with these substances may aggravate an existing skin condition, particularly in individuals who have a prior history of skin problems or allergy. Considering this, carefully answer the following questions:

Yes No Do you currently have a skin disorder, dermatitis or chronic skin problem?

Yes No Has employment or household use ever caused a skin disorder due to contact with fiberglass, resins, spray, glue, bonding agents or other similar agents?

Yes No As an adult, have you ever had a skin allergy or skin reaction to any of the following: Inhalants (pollens, dust, molds, animal dander) Clothing materials (wool, silk, synthetics, dyes) Metals or jewelry Latex or rubber products Detergents Specify type of allergy or reaction _______________________________

I hereby attest that information provided herein is true and correct to the best of my knowledge. I confirm that I am able to perform the essential functions of the job position with or without reasonable accommodations. Requested reasonable accommodations, if any, are listed below: ____________________________________________________________________________________________________________________________________________________________________________________________________________________ Additional Comments:___________________________________________________________________________________________________________________________________________________________________________________________________________

My signature below indicates that I am aware this is a post-offer of employment medical questionnaire:

Signature:__________________________________________ Date:______________________________________________

2014 - 2015