HEMPSTEAD INDEPENDENT SCHOOL DISTRICT

HEMPSTEAD INDEPENDENT SCHOOL DISTRICT

P.O. Box 1007~ 1440 13th Street ~ Hempstead, TX 77445 Phone: 979-826-3304 Fax: 979-826-5510

TO: ALL SUBSTITUTE TEACHER APPLICANTS FROM: HUMAN RESOURCES COORDINATOR

RE: APPLICATION PROCESS

Thank you for your interest in substitute teaching at Hempstead ISD.

To be considered for a substitute teacher position, all applicants must complete and return the following documents which are included in the Substitute Application:

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Employment Application for Substitute Teachers

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Consent to Perform Investigative Consumer Report

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W4

?

Public Access Information Option Form

?

Notice Regarding Asbestos and Pest Control

?

Workers' Compensation Election Form

?

Notice Regrading Drug Free Schools

?

Notice of Reasonable Assurance

?

Demographic Data Sheet

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PEIMS Data Standards

?

DPS Computerized Criminal History (CCH) Verification

?

Direct Deposit Agreement Form

In addition, all applicants must submit the following credentials:

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A Copy of your High School Diploma or GED (if not degreed)

?

Official college transcripts showing degrees earned, if applicable

?

Copies of all teaching and professional certifications or licenses, if applicable

?

Fingerprinting receipt as required by Senate Bill 9

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Social Security Card

?

Valid Driver's License

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Certificates of Completion for General Substitute Teaching and Bloodborne Pathogens Courses

Return all documents in person to the Central Office located at the address above.

Applications from individuals who hold a valid teaching certificate will be processed throughout the year and they will be added to the Substitute Teacher List if their application is approved.

Applications from individuals who do not hold a valid teaching certificate will be processed as they are received; however, they will not be added to the Substitute Teacher List until they attend a training class sponsored by Hempstead ISD. Only those individuals whose applications have been approved will be invited to attend the district sponsored training. Training classes are usually offered on the 3rd, Thursday of each month. Seating is limited, therefore, in order to secure a seat in the training, applicants are encouraged to return all documents as soon as possible.

EMPLOYMENT APPLICATION FOR SUBSTITUTE TEACHER

Hempstead

Independent School District 1440 13th Street ~ Hempstead, Texas 77445 Phone: (979) 826-3304 Fax: (979) 826-5510

Hempstead ISD considers applicants for all positions without regard to age, race, color, national origin, religion, sex, marital status, veteran or military status, disability or any other legally protected status.

PERSONAL DATA Date of Application

AN EQUAL OPPORTUNITY EMPLOYER Email

Last Name Address

First Name City

Middle Name State

Zip Code

Work Phone #

Home Phone #

Cell Phone #

Other name(s) that may appear on official records

(used for certification, reference and criminal history record checks)

POSITION

Please include the following credentials with your application: * A Copy of your High Diploma or GED (if not degreed) * All transcripts showing degrees earned, if applicable * All teaching and professional certificates or licenses, if applicable

Have you ever been employed by Hempstead ISD ?

Yes

No

If you answered yes, provide dates of employment

EDUCATION/TRAINING

Check the highest level of education attained: High School Graduate Two or more years of college Other training or education

GED Bachelor's Degree

Name & Location of Schools Attended

Course of Study and Major/Minor

Less than two years of college Master's Degree

Diploma, Degree, Certificate or License Held

Year Graduated

Page 1 of 4

EMPLOYMENT APPLICATION FOR SUBSTITUTE TEACHER

CERTIFICATION Certificate or License currently held: None Valid Texas Valid Other State Texas Emergency Texas One-Year: Expires: Texas Temporary Administrative: Expires:

Level(s) of Certification:

Areas of Specialization/Endorsements (as listed on certification):

TEACHING EXPERIENCE

Name & Location of School (begin with most recent experience)

Type of Assignment

Date Taught

Reason for Leaving

Other Work Experience

Please provide a list of all other jobs or administrative positions you have held in the past 10 years. Send additional sheets if necessary. Send your resume if available.

School District/Firm Name

Position/Title

Dates Employed

Reason for Leaving

Page 2 of 4

Assignment Preference

EMPLOYMENT APPLICATION FOR SUBSTITUTE TEACHER

Day(s) of week

Every day or only the following:

Monday

Tuesday

Wednesday

Thursday

Friday

Assignment

Any or only the following:

Elementary

Middle School

High School

Special Education

Disciplinary Alternative Education Program (Grades Elementary - High School)

General Information

Do you have a relative who serves on the Hempstead ISD Board of Trustees?

Yes

No

If yes, please provide the relative's name and relationship:

Can you, after employment, submit verification of your lega rights to work in the United States?

Yes

No

Have you ever been convicted of, pleaded guilty or no contest (nolo contendre) to, or received probation, suspension, or deferred

adjudication for a felony offense involving moral turpitude (including, but not limited to, theft, rape, murder, swindling, and indecency

with a minor)?

Yes

No

If yes, please state where, when, and the nature of the offense; indicate whether charges were dismissed as a condition of probation, suspension, or deferred adjudication:

*A felony conviction is not an automatic bar to employment. The district will consider the nature, date, and relationship between the offense and the position for which you are applying.

References

Please list references the district may contact regarding your work history. Please include all managers and supervisors who evaluated or supervised your performance at your last two employers.

Full Name of Reference

School District/ Firm

Mailing Address

Position/Title

Area Code & Phone Number

Page 3 of 4

EMPLOYMENT APPLICATION FOR SUBSTITUTE TEACHER

Verification

I hereby affirm that all information provided in this application is true and accurate to the best of my knowledge and understand that any deliberate falsifications, misrepresentations, or omissions of fact may be grounds for rejection of my application or dismissal from subsequent employment.

I authorize the references listed on the previous page to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all such parties from liability for any damage that may result from furnishing the same to you.

I understand that the District is authorized by Texas Education Agency Code 22.083 to obtain criminal history record information on applicants the district intends to employ.

Signature of Applicant

Date

This application becomes the property of the district. the district reserves the right to accept or reject it. The application shall be considered active for 12 months. If you have not received a response during this time period, you may reapply or reactivate your application.

*Applicants for all positions are considered without regard to age, race, color, national origin, religion, sex, marital status, veteran or military status, disability or any other legally protected status.

The District Title IX Coordinator is:

Eric Mullens 1440 13th St. /P. O. Box 1007 Hempstead, TX 77445 Phone: 979-826-3304 X235

Page 4 of 4

Last Name

HEMPSTEAD ISD

CONSENT TO PERFORM INVESTIGATIVE CONSUMER REPORT IN COMPLIANCE WITH FCRA (FAIR CREDIT REPORTING ACT)

First Name

Middle Name

Maiden or other name(s) used in any and all other records of birth records of residence.

*Address

Apartment or #

City

State

Zip Code

**Date of Birth

SSN

**Gender

**Race

**Driver's License #

**Driver's License # Expiration Date

** State Issued Driver License's

*AS SHOWN ON THE ORIGINAL APPLICATION **TO BE USED FOR CRIMINAL HISTORY CHECKS ONLY AND NOT A PART OF THE PERSONNEL FILE.

In connection with my application for employment, my continued employment, or in connection with my desire to engage in volunteer activities, I have been advised and I hereby consent and authorize the Employer and its agent, at any time during or subsequent to my application process, to conduct an investigative consumer report that may include but not limited to, a criminal record check, employment and education verification, personal references, personal interviews, my personal credit history, and driving record. I do hereby consent to Employer's use of any information provided on this form or during the application process in performing the investigative consumer report. Employer has informed me that I have the right to review and challenge any negative information that would adversely impact a decision to offer employment. I agree to release, indemnify and hold harmless Employer and any reporting agency Employer uses with regard to any information reported by the reporting agency. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained from a consumer reporting agency. If so, I will be notified and given the opportunity to clear up any mistaken information reported within a reasonable time frame established within the sole discretion of Employer. Under the Fair Credit Reporting Act, I have been advised that upon request I will be provided the name, address, and telephone number of the reporting agency as well as the nature, substance and source of all information. I acknowledge that facsimile, copy, online submission, or email shall be as valid as the original.

The following are my responses to questions regrading my criminal history (if any).

1. Have you ever been convicted or plead guilty before a court for any federal, state or municipal criminal offense? (exclude minor traffic

misdemeanors).

Yes

No

If yes, please provide details below.

State:

County:

Date of Offense:

Details of Conviction:

2. Have you ever received deferred adjudication or similar disposition for any federal, state, or municipal criminal offense?

If yes, please provide details below.

Yes

No

State:

County:

Date of Offense:

Details of Offense:

3. Have you ever received probation or community supervision for any federal, state or municipal criminal offense?

Yes

No

If yes, please provide details below.

State:

County:

Date of Offense:

Details of Supervision:

4. Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States?

Yes

No

If yes, please provide details below.

Country:

City:

Date of Offense:

Details of Conviction:

5. As of the date of this consent form, do you have any pending charges against you?

Yes

No

If yes, please provide details below.

State:

County:

Date of Arrest:

Details of Pending Charges:

THIS SECTION IS TO BE USED TO LIST ALL COUNTIES AND STATES OF RESIDENCE SINCE HIGH SCHOOL GRADUATION OR AGE 18. This section must be completed even if you have only lived at one address listed at the top of the form.)

City/Town

County

State

I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS CONSENT FORM IS TRUE, CORRECT AND COMPLETE. IF ANY INFORMATION PROVES TO BE INCORRECT OT INCOMPLETE, I UNDERSTAND THAT GROUNDS FOR CANCELING OF ANY AND ALL OFFERS OF EMPLOYMENT WILL EXIST AND MAY BE USED AT THE DISCRETION OF THE EMPLOYER.

Signed this Day

day of

Month

, Year

Applicant (Print Name)

Applicant's Signature

Form W-4 (2017)

Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.

Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2017 expires February 15, 2018. See Pub. 505, Tax Withholding and Estimated Tax.

Note: If another person can claim you as a dependent on his or her tax return, you can't claim exemption from withholding if your total income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:

? Is age 65 or older,

? Is blind, or

? Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions don't apply to supplemental wages greater than $1,000,000.

Basic instructions. If you aren't exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.

Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.

Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.

Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2017. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).

Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at w4.

Personal Allowances Worksheet (Keep for your records.)

A Enter "1" for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . . . A

B

Enter "1" if:

{

? You're single and have only one job; or ? You're married, have only one job, and your spouse doesn't work; or

} . .

B

? Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less.

C Enter "1" for your spouse. But, you may choose to enter "-0-" if you are married and have either a working spouse or more than one

job. (Entering "-0-" may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . . . D

E Enter "1" if you will file as head of household on your tax return (see conditions under Head of household above) . . . . . E

F Enter "1" if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . . . . . F

(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)

G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

? If your total income will be less than $70,000 ($100,000 if married), enter "2" for each eligible child; then less "1" if you

have two to four

eligible children or less "2" if you have five or more eligible children.

? If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter "1" for each eligible child . . . . G

H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.)

H

? If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions

For accuracy, complete all worksheets that apply.

{

and Adjustments Worksheet on page 2.

? If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.

? If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

W-4 Form

Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate

Whether you are entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

2017

1 Your first name and middle initial

Last name

2 Your social security number

Home address (number and street or rural route)

3

Single

Married

Married, but withhold at higher Single rate.

City or town, state, and ZIP code

Note: If married, but legally separated, or spouse is a nonresident alien, check the "Single" box.

4 If your last name differs from that shown on your social security card, check here. You must call 1-800-772-1213 for a replacement card.

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)

5

6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions for exemption.

? Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and

? This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write "Exempt" here . . . . . . . . . . . . . . . 7 Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

Employee's signature (This form is not valid unless you sign it.)

8 Employer's name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)

9 Office code (optional)

Date 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Cat. No. 10220Q

Form W-4 (2017)

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