Fillable APPLICATION UPDATE FOR CLASSIFIED EMPLOYMENT (Long Beach Unified School District)

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APPLICATION UPDATE FOR CLASSIFIED EMPLOYMENT (Long Beach Unified School District)

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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 Ex
p
erience since ori
g
inal a
pp
lication submi
t
ted.
DATE DUTIES EMPLOYER
From:
Month/Year
To:
Month/Year
Hours per Week:
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:
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
Tele
p
hone
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:
Perscert:OnBoarding: App update – 8/2007, Revised 12/2017. Rev. 3/2020
LBUSD PERSONNEL COMMISSION
REPORT OF CONVICTIONS AND NOTICE OF FINGERPRINTING FEE
Name (Last, First & Middle): Social Security Number:
Please read the provided information carefully. All applicants must complete this form in its entirety.
1.
If you have been convicted of any criminal offense, please specify and explain all convictions on this form.
a.
You must report all convictions for sex and/or drug offenses specified in Education Code sections 44010
and 44011 and any convictions for serious or violent felonies specified in Penal Code sections 667.5
and 1192.7.
b.
Any convictions set aside pursuant to Penal Code section 1203.4 must be disclosed, as such
convictions are by law convictions for the purpose of this question (see Education Code section 44009).
2.
A conviction will not necessarily result in automatic disqualification.
3.
You are solely responsible for making the determination of whether a conviction must be disclosed. District or
Personnel Commission staff cannot and will not assist you.
4.
Failure to report an otherwise reportable conviction will not be excused by your misunderstanding of the law.
Have you been convicted of any criminal offense?
If yes, please use the space below to explain in detail, the incident(s) and the surrounding circumstances,
outcome, etc.
No
Yes
Name of Offense:
Offense Code:
Date
Month & Year:
Location
City & State:
Infraction,
Misdemeanor,
or Felony:
If Imprisoned,
How Long:
If Fined
$ Amount:
If Probation
From---To:
1.

2.

3.

Explanation of Events (use additional pages if necessary):
Complete back side of this form
Please read the provided information carefully. All applicants must complete this form in its entirety.
1.
You must include traffic violations only if they resulted in the following:
a.
Convictions and infractions
b.
Convictions following probation
c.
Issuance of a warrant for failure to pay fines or appear for sentencing
Do you have any traffic violations that resulted in the listed conditions above?
If yes, please use the space below to explain in detail, the incident(s) and the surrounding circumstances,
outcome, etc.
No
Yes
Date
Month &
Y
ear:
Location
City & State:
Outcome
License Status:
1.

2.

3.

Explanation of Events (use additional pages if necessary):
Notice of Fingerprinting Fee
In accordance with the Board of Education policies and provisions of the Education Code, all prospective school district
employees are fingerprinted, and fingerprints are submitted to the Department of Justice and Federal Bureau of
Investigation for verification of any information given prior to the employee starting work. Fingerprinting fees are the
financial responsibility of the employee and are collected through payroll deductions from the first two payroll checks.
If the fingerprint report from the Department of Justice and/or Federal Bureau of Investigation shows convictions that
you do not list, you will be disqualified from examination or terminated from employment.
I declare that I have read and understand the Report of Convictions and Notice of Fingerprinting Fee and the answers
I have given are true, correct, and complete. I understand it is my responsibility to list any and all convictions, and that
anything I may have forgotten or failed to list will result in rejection for employment or dismissal from employment.
Signature of Applicant: Date:
Report of Convictions and Notice of Fingerprinting Fee (Revised) 03.2019
Please review this entire form for completion before submitting
EMPLOYEE DEMOGRAPHIC DATA
VA#
Board Date
Employee Number
Last Name:
First Name:
MI:
Preferred Name:
Social Security Number:
Home Address:
City/State:
Zip Code:
Primary Phone Number:
Email Address:
Birth Date:
Gender:
Secondary Phone Number:
Ethnic Code: (Select appropriate origin)
Citizenship:
(Select one of the following)
◻ I – American Indian or
Alaskan Native
◻ B – Black or African American*
◻ A citizen or national of the United
States
◻ A Permanent Resident
(Alien #_____________________)
◻ An alien authorized to work until
_______/________/____
◻ Alien # or Admission #
(___________________________)
◻ H – Hispanic or Latino
(Spanish culture or origin)
◻ W – White*
◻ A – Asian*
◻ P – Native Hawaiian or Pacific Islander*
◻ F – Filipino (Philippines Islands)*
◻ O – Two or more races*
*Not of Hispanic or Latino Origin
Pre-School (Only)
Health Screen Report: (LIC 503)
DSS Clearance:
◻ Immunization Requirements for Adults: (SB 792)
Official Use Only
Please select one:
◻ TB
◻ X-Ray
◻ Risk Assessment
◻ Quantiferon/Gold
F/P Clearance
First Aid:
Contract Date:
SC Date:
CBEST Date
CPR:
Cert Sen Date:
Cert Flag: ◻ Yes ◻ No
Verified By:
Initials
Date
Employee Signature:
Signature
Date
Male
Female
Non-Binary
click to sign
signature
click to edit
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
___________________________________________________ _______________________
Designee’s Cellphone Number Alternative Phone Number
or in the event of death of Designee #1:
No. 2 ____________________________________________________ _______________________
Designee’s Full Name Relationship
________________________________________________________________________________
Address City State Zip Code
___________________________________________________ _______________________
Designee’s Cellphone Number Alternative Phone Number
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 Employee Number or Social Security Number
Return this form to Human Resource Services
Warrant Recipient Designation Form Revised Feb 2018
4400 Ladoga Avenue, Lakewood, CA 90713
(
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 (4119.21)
Initial
______ 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 4119.1- AR 4119.11 and 5145.7 –
AR 5145.7).
______ Policy on Nondiscrimination in Employment (BP 4030).
Initial
______ Policy on Nondiscrimination/Harassment-Students (BP 5145.3).
Initial
______ Policy on Nondiscrimination in District Programs and Activities (BP 0410).
Initial
______ Policy on Bullying (BP 5131.2).
Initial
______ Policy on Hate-Motivated Behavior (BP 5145.9).
Initial
______ Policy on Uniform Complaint Procedures (BP 1312.3).
Initial
______ Policy on a Drug and Alcohol-Free Workplace (BP 4020).
Initial
______ Policy on a Positive School Climate (BP 5137).
______ Policy on a Comprehensive Safety Plan (BP 0450).
______ Policy on Employee Use of Technology (BP 4040).
Initial
______ Policy on District Internet and Electronic Mail Guidelines
Initial
_______ Policy on Unauthorized Release of Confidential/Privileged Information (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 in your personnel file in the Human Resource Services office
as required by law.
Revised 12/17
Last First MI
Initial
Initial
Initial
Initial
Initial
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 10/21/2019
Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an
employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the
documentation presented has a future expiration date may also constitute illegal discrimination.
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.)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
-
-
Employee's E-mail Address
Employee's Telephone Number
U.S. Social Security Number
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until
(See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1
Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Employer Completes Next Page
Form I-9 10/21/2019
Page 2 of 3
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Last Name (Family Name) M.I.
First Name (Given Name)
Employee Info from Section 1
Citizenship/Immigration Status
List A
Identity and Employment Authorization
Identity
Employment Authorization
OR List B AND List C
Additional Information
QR Code - Sections 2 & 3
Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Today's Date (mm/dd/yyyy)
Signature of Employer or Authorized Representative
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
B. Date of Rehire (if applicable)
Date (mm/dd/yyyy)
Document Title Document Number
Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative
Long Beach Unified School District
1515 Hughes Way
Long Beach
CA
90810
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machine-
readable immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
Documents that Establish
Both Identity and
Employment Authorization
6. Passport from the Federated States
of Micronesia (FSM) or the Republic
of the Marshall Islands (RMI) with
Form I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are
unable to present a document
listed above:
1. Driver's license or ID card issued by a
State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address
9. Driver's license issued by a Canadian
government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
8. Native American tribal document
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 local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish
Identity
LIST B
OR AND
LIST C
7. Employment authorization
document issued by the
Department of Homeland Security
1. A Social Security Account Number
card, unless the card
includes one of
the following restrictions:
2. Certification of report of birth issued
by the Department of State (Forms
DS-1350, FS-545, FS-240)
3. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
4. Native American tribal document
6. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3
Form I-9 10/21/2019
Examples of many of these documents appear in the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
STATE OF CALIFORNIA
BCIA 8016
(Rev. 04/2020)
DEPARTMENT OF JUSTICE
PAGE 1 of 4
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
A0333
ORI (Code assigned by DOJ)
Authorized Applicant Type
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
Long Beach Unified School District 06070
Agency Authorized to Receive Criminal Record Information
Mail Code (five-digit code assigned by DOJ)
4400 Ladoga Avenue
Dale Culton
Street Address or P.O. Box Contact Name (mandatory for all school submissions)
Lakewood
CA 90713
(
562) 435-5708
City
Applicant Information:
State
ZIP Code
Contact Telephone Number
Last Name
First Name Middle Initial Suffix
Other Name: (AKA or Alias)
Last Name First Name
Suffix
Date of Birth
Sex
Male Female
Driver's License Number
Billing
Height Weight Eye Color Hair Color
Number
(Agency Billing Number)
Place of Birth (State or Country) Social Security Number
Misc.
Number
(Other Identification Number)
Home
Address
Street Address or P.O. Box City
State
ZIP Code
I have received and read the included Privacy Notice, Privacy Act Statement, and Applicant's Privacy Rights.
Applicant Signature
Date
OCA Number (Agency Identifying Number)
(If the Level of Service indicates FBI, the fingerprints will be used to check the
criminal history record information of the FBI.)
If re-submission, list original ATI number:
(Must
provide proof of rejection)
Original ATI Number
Employer (Additional response for agencies specified by statute):
Employer Name
Street Address or P.O. Box
Telephone N
umber (optional)
City
State
ZIP Code
Mail Code (five digit code assigned by DOJ)
Live Scan Transaction Completed By:
Date
ATI Number
Name of Operator
LSID
Transmitting Agency Amount Collected/Billed
Your Number:
Level of Service:
DOJ
FBI
Classified Employee
STATE OF CALIFORNIA
BCIA 8016
(Rev. 04/2020)
DEPARTMENT OF JUSTICE
PAGE 2 of 4
REQUEST FOR LIVE SCAN SERVICE
Privacy Notice
As Required by Civil Code § 1798.17
Collection and Use of Personal Information. The California Justice Information Services (CJIS)
Division in the Department of Justice (DOJ) collects the information requested on this form as authorized
by Business and Professions Code sections 4600-4621, 7574-7574.16, 26050-26059, 11340-11346, and
22440-22449; Penal Code sections 11100-11112, and 11077.1; Health and Safety Code sections 1522,
1416.20-1416.50, 1569.10-1569.24, 1596.80-1596.879, 1725-1742, and 18050-18055; Family Code
sections 8700-87200, 8800-8823, and 8900-8925; Financial Code sections 1300-1301, 22100-22112,
17200-17215, and 28122-28124; Education Code sections 44330-44355; Welfare and Institutions Code
sections 9710-9719.5, 14043-14045, 4684-4689.8, and 16500-16523.1; and other various state statutes
and regulations. The CJIS Division uses this information to process requests of authorized entities that
want to obtain information as to the existence and content of a record of state or federal convictions to
help determine suitability for employment, or volunteer work with children, elderly, or disabled; or for
adoption or purposes of a license, certification, or permit. In addition, any personal information collected
by state agencies is subject to the limitations in the Information Practices Act and state policy. The DOJ's
general privacy policy is available at http://oag.ca.gov/privacy-policy.
Providing Personal Information. All the personal information requested in the form must be provided.
Failure to provide all the necessary information will result in delays and/or the rejection of your request.
Access to Your Information. You may review the records maintained by the CJIS Division in the DOJ
that contain your personal information, as permitted by the Information Practices Act. See below for
contact information.
Possible Disclosure of Personal Information. In order to process applications pertaining to Live Scan
service to help determine the suitability of a person applying for a license, employment, or a volunteer
position working with children, the elderly, or the disabled, we may need to share the information you give
us with authorized applicant agencies.
The information you provide may also be disclosed in the following circumstances:
• With other persons or agencies where necessary to perform their legal duties, and their use of
your information is compatible and complies with state law, such as for investigations or for
licensing, certification, or regulatory purposes.
• To another government agency as required by state or federal law.
Contact Information. For questions about this notice or access to your records, you may contact the
Associate Governmental Program Analyst at the DOJ's Keeper of Records at (916) 210-3310, by email at
keeperofrecords@doj.ca.gov, or by mail at:
Department of Justice
Bureau of Criminal Information & Analysis
Keeper of Records
P.O. Box 903417
Sacramento, CA 94203-4170
STATE OF CALIFORNIA
BCIA 8016
(Rev. 04/2020)
DEPARTMENT OF JUSTICE
PAGE 3 of 4
REQUEST FOR LIVE SCAN SERVICE
Privacy Act Statement
Authority. The FBI's acquisition, preservation, and exchange of fingerprints and associated
information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application,
supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544,
Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated
information is voluntary; however, failure to do so may affect completion or approval of your
application.
Principal Purpose. Certain determinations, such as employment, licensing, and security clearances,
may be predicated on fingerprint-based background checks. Your fingerprints and associated
information/biometrics may be provided to the employing, investigating, or otherwise responsible
agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's
Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and
latent fingerprint repositories) or other available records of the employing, investigating, or otherwise
responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI
after the completion of this application and, while retained, your fingerprints may continue to be
compared against other fingerprints submitted to or retained by NGI.
Routine Uses. During the processing of this application and for as long thereafter as your fingerprints
and associated information/biometrics are retained in NGI, your information may be disclosed pursuant
to your consent, and may be disclosed without your consent as permitted by the Privacy Act
of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register,
including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses
include, but are not limited to, disclosures to: employing, governmental, or authorized non-
governmental agencies responsible for employment, contracting, licensing, security clearances, and
other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice
agencies; and agencies responsible for national security or public safety.
STATE OF CALIFORNIA
BCIA 8016
(Rev. 04/2020)
DEPARTMENT OF JUSTICE
PAGE 4 of 4
REQUEST FOR LIVE SCAN SERVICE
Noncriminal Justice Applicant's Privacy Rights
As an applicant who is the subject of a national fingerprint-based criminal history record check for
a noncriminal justice purpose (such as an application for employment or a license, an immigration
or naturalization matter, security clearance, or adoption), you have certain rights which are
discussed below.
• You must be provided written notification1 that your fingerprints will be used to check the
criminal history records of the FBI.
• You must be provided, and acknowledge receipt of, an adequate Privacy Act Statement
when you submit your fingerprints and associated personal information. This Privacy Act
Statement should explain the authority for collecting your information and how your
information will be used, retained, and shared.
2
• If you have a criminal history record, the officials making a determination of your
suitability for the employment, license, or other benefit must provide you the opportunity
to complete or challenge the accuracy of the information in the record.
•
The officials must advise you that the procedures for obtaining a change, correction, or
update of your criminal history record are set forth at Title 28, Code of Federal
Regulations (CFR), Section 16.34.
• If you have a criminal history record, you should be afforded a reasonable amount of time
to correct or complete the record (or decline to do so) before the officials deny you the
employment, license, or other benefit based on information in the criminal history record. 3
You have the right to expect that officials receiving the results of the criminal history record check
will use it only for authorized purposes and will not retain or disseminate it in violation of federal
statute, regulation or executive order, or rule, procedure or standard established by the National
Crime Prevention and Privacy Compact Council.
4
If agency policy permits, the officials may provide you with a copy of your FBI criminal history
record for review and possible challenge. If agency policy does not permit it to provide you a copy
of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI.
Information regarding this process may be obtained at https://www.fbi.gov/services/cjis/identity-
history-summary-checks.
If you decide to challenge the accuracy or completeness of your FBI criminal history record, you
should send your challenge to the agency that contributed the questioned information to the FBI.
Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your
challenge to the agency that contributed the questioned information and request the agency to
verify or correct the challenged entry. Upon receipt of an official communication from that agency,
the FBI will make any necessary changes/corrections to your record in accordance with the
information supplied by that agency. (See 28 CFR 16.30 through 16.34.)
You can find additional
information on the FBI website at
https://www.fbi.gov/about-us/cjis/background-checks.
1
Written notification includes electronic notification, but excludes oral notification
2 https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement
3
See 28 CFR 50.12(b)
4
See U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c)
4400 LADOGA AVENUE, LAKEWOOD, CALIFORNIA 90713 TELEPHONE: (562) 435-5708
“We find qualified candidates to support the District’s needs”
TO: Regular, Limited Term, Substitute and Exempt Employment Candidates
SUBJECT: FINGERPRINT PROCESSING FEE AUTHORIZATION
Congratulations on your tentative offer of employment with the Long Beach Unified
School District!
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.
You will need the following clearances:
Department of Justice (DOJ) $32.00
Federal Bureau of Investigation (FBI) $17.00
BioMetrics Transaction Fee
$10.00
Fingerprinting for your DOJ, FBI
+ CACI clearance sent to DSS
$74.00
Your charge for fingerprinting will be $
For your convenience, this amount will be deducted in two equal payments from your first two pay
checks.
By signing this form I acknowledge and authorize the Long Beach Unified School District to deduct
the
cost of employment fingerprinting from my pay checks.
Print Name Social Security Number
Signature Date
-------------------------------------------------------------------------------------------------------------------------------------
Do Not Write Below This Line
Prepared by (site staff signature)
Rev. 3/2020
Distribution:
Employee
Payroll
HRS/Em
p
lo
y
ee File
PERS-EAMD-801 (6/2018) Page 1 of 4
California Public Employees’ Retirement System
P.O. Box 942709 Sacramento, CA 94229-2709
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
|
Fax: (916) 795-4166
www.calpers.ca.gov
Employer Account Management Division
Dear Member,
The California Public Employees’ Retirement System (CalPERS) requires all members hired after
January 1, 2013 complete the Reciprocal Self-Certification Form (PERS-EAMD-801) to provide essential
information that will be used by your employer to enroll you in CalPERS membership.
This form obtains information regarding your membership in other qualifying public retirement systems
and must be returned to your employer within 10 business days of receipt. Use the instructions provided
on the back of the form and reference the List of Qualifying Public Retirement Systems for assistance.
Information regarding your membership in a defined benefit plan for any of the listed qualifying public
retirement system must be provided. However, information related to CalPERS membership should
not be included when completing this form, as this data is already stored in the CalPERS system.
It is your responsibility to ensure the accuracy and completeness of the information you provide.
Inaccurate information may result in adjustments to your account which could lead to adverse impacts
such as incurring financial obligations that you and your employer will be responsible to fulfill.
For more information regarding the Reciprocal Self-Certification Form, please visit our website at
www.calpers.ca.gov.
Please note: The completion of the Reciprocal Self-Certification Form does not establish reciprocity, nor
is it a request to establish reciprocity. To request that reciprocity be established, download the When
You Change Retirement Systems (PUB 16) publication to obtain the Confirmation of Intent to Establish
Reciprocity When Changing Retirement Systems (PERS-CASD-255) form. This publication is available at
www.calpers.ca.gov.
Sincerely,
Membership Services
Enclosures: List of Qualifying Public Retirement Systems in California, Reciprocal Self-Certification
Form, and Directions for Completing Reciprocal Self-Certification Form
PERS-EAMD-801 (6/2018) Page 2 of 4
List of Qualifying Public Retirement Systems in California
Name of Public Retirement System
Qualifications:
Alameda County Employees’ Retirement Association^
City and County of San Francisco Employees’ Retirement System*
City of Concord Retirement System*
City of Costa Mesa Public Retirement System*
Safety only
City of Fresno Retirement System
City of Pasadena Fire and Police Retirement System
Fire and police only
City of San Clemente*
Non-safety (miscellaneous) only
Contra Costa County Employees’ Retirement Association^
Contra Costa Water District
East Bay Municipal Utility District
East Bay Regional Park District
Safety only
Fresno County Employees’ Retirement Association^
Imperial County Employees’ Retirement Association^
Judges Retirement System II
Kern County Employees’ Retirement System^
Legislators’ Retirement System
Los Angeles City Employees’ Retirement System
Non-safety (miscellaneous) only; L.A. Fire and Police Pension
System and L.A. Water and Power Employees’ Retirement
System not eligible
Los Angeles County Employees’ Retirement Association^
Los Angeles County Metropolitan Transportation Authority
Non-contract Employees’ Retirement Income Plan, formerly
Southern California Rapid Transit District
Marin County Employees’ Retirement Association^
Mendocino County Employees’ Retirement Association^
Merced County Employees’ Retirement Association^
Oakland Municipal Employees’ Retirement System (City of
Oakland)
Non-safety (miscellaneous) only
Orange County Employees’ Retirement System^
Sacramento City Employees’ Retirement System*
Sacramento County Employees’ Retirement System^
Defined benefit plan only; cash balance plans not eligible
San Bernardino County Retirement Association^
San Diego City Employees’ Retirement System
Defined benefit plan only; cash balance plans not eligible
San Diego County Employees’ Retirement Association^
San Joaquin County Employees’ Retirement Association^
San Jose Federated City Employees’ Retirement System
San Luis Obispo County Pension Trust
San Mateo County Employees’ Retirement Association^
Santa Barbara County Employees’ Retirement System^
Sonoma County Employees’ Retirement Association^
Stanislaus County Employees’ Retirement Association^
State Teachers’ Retirement System
Defined benefit plan only; cash balance plans not eligible
Tulare County Employees’ Retirement Association^
University of California Retirement Program
Defined benefit plan only; cash balance plans not eligible
Ventura County Employees’ Retirement Association^
*=Also CalPERS-covered agency ^=1937 Act Counties
PERS-EAMD-801 (6/2018) Page 3 of 4
California Public Employees’ Retirement System
P.O. Box 942709 Sacramento, CA 94229-2709
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
|
Fax: (916) 795-4166
www.calpers.ca.gov
Reciprocal Self-Certification Form
Complete the following information and return this form to your personnel office within 10 business days. To ensure this form is completed
correctly, please reference the enclosed List of Qualifying Public Retirement Systems and instructions.
Section 1. Member Information
Member Name: (Last) (First) (Middle)
Date of Birth: CalPERS ID:
Membership Status in Qualifying Public Retirement Systems:
I have not been a member of a qualifying public retirement system in California. (skip to section 3)
I have membership in a defined benefit plan under a qualifying public retirement system in California other than CalPERS.
(complete section 2 with membership information for each qualifying public retirement system)
Section 2. Qualifying Reciprocal Membership Information
Name of Most Recent Public Retirement System:
Membership Date:
/ /
Separation Date*:
/ /
☐Retired* or ☐Refunded*
Date: / /
Name of Prior Public Retirement System:
Membership Date:
/ /
Separation Date*:
/ /
☐Retired* or ☐Refunded*
Date: / /
Name of Prior Public Retirement System:
Membership Date:
/ /
Separation Date*:
/ /
☐Retired* or ☐Refunded*
Date: / /
*Please provide dates, if applicable. Not all sections may be applicable for each Public Retirement System.
Section 3. Sign and Certify
I understand that by accepting employment in a qualified public retirement system, I am subject to the applicable laws and
regulations of that system. I also understand that completing this form is not a request to establish reciprocity.
I hereby certify that the foregoing information has been verified with the qualifying public retirement system as true and correct
and any information found to be incorrect may require corrections to my CalPERS account including, but not limited to, my
retirement enrollment level and adjustments to my member contributions. CalPERS may make any necessary corrections to my
account to ensure I am properly enrolled and eligible to receive the correct retirement benefits.
Member Signature: Date:
Section 4. To Be Completed by Employer Only
Name of CalPERS Agency:
CalPERS Business Partner ID: Member’s Enrollment Eligibility Date:
Designee of Employer: (print name) Designees’ Title:
Designee Signature: Date:
The employer must retain this form in the member’s file for auditing purposes.
For more direction regarding how to process the Reciprocal Self-Certification Form, please refer to our employer reference guides.
Long Beach Unified School District
1315715064
PERS-EAMD-801 (6/2018) Page 4 of 4
Instructions for Completing the Reciprocal Self-Certification Form
Section 1.
Member
Information
• Complete the required fields with your name, date of birth, and CalPERS ID.
• Check one of the appropriate boxes to indicate if you have had membership in a defined
benefit plan in one of the qualifying public retirement systems named on the enclosed list.
- If you have not been a member of any of the qualifying public retirement systems,
mark the first box and skip to section 3.
- If you have membership in a defined benefit plan of any of the qualifying public
retirement systems on the enclosed list, mark the second box and continue to section
2.
- This form is to obtain information regarding your membership in other qualifying public
retirement systems; do not include CalPERS membership on this form.
Section 2.
Qualifying
Reciprocal
Membership
Information
• In the first column, titled “Name of Public Retirement System,” list the name of any qualifying
public retirement systems you are a member of a defined benefit plan.
- If you are a member of multiple qualifying public retirement systems, please provide
the name of each system beginning with the most recent in descending order.
- Please reference the enclosed List of Qualifying Public Retirement Systems in
California. Only systems named on this list should be provided on the Reciprocal Self-
Certification Form.
• In the second column, titled “Membership Date,” list your membership date in the qualifying
public retirement system.
- You must provide a full date, including month, date, and year, which corresponds to
each qualifying public retirement system listed.
- If you are unsure of your membership date, please contact the qualifying public
retirement system to confirm information prior to completing the form.
• In the third column, titled “Separation Date,” list your separation date from the qualifying
public retirement system.
- This section may not be applicable for all qualifying public retirement systems. If you
have not separated from the qualifying public retirement system, leave this field blank.
- If you have separated from the qualifying public retirement system, you must provide a
full date including month, date, and year.
- If you are unsure of your separation date, please contact the qualifying public
retirement system to confirm information prior to completing the form.
• In the fourth column, titled “Retired or Refunded,” indicate if you have retired or refunded
from the qualifying public retirement system.
- This section may not be applicable for all qualifying public retirement systems. If you
have not retired or refunded from the qualifying public retirement system, leave this
field blank.
- If you have retired or refunded from the qualifying public retirement system, mark the
appropriate box and provide a full date including month, date, and year.
- Retired: You have separated from the qualifying public retirement system and receive a
monthly retirement allowance.
- Refunded: You have terminated your membership in the qualifying public retirement
system by withdrawing your contributions.
Section 3.
Sign and
Certify
• Please read the statement. Then, sign your name and date the document before returning it to
your personnel office.
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
The information requested is collected pursuant
to the Government Code (sections
20000 et seq.)
and will be used for administration of Board
duties under the Retirement Law, the Social
Security Act, and the Public Employees’ Medical
and Hospital Care Act, as the case may be.
Submission of the requested information is
mandatory. Failure to comply may result in
CalPERS being unable to perform its functions
regarding your status.
Please do not include information that is
not requested.
Social Security Numbers
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
Social Security number has already been provided,
disclosure is voluntary. Due to the use of Social
Security numbers by other agencies for
identification purposes, we may be unable to
verify eligibility for benefits without the number.
Social Security numbers are used for the
following purposes:
1. Enrollee identification
2. Payroll deduction/state contributions
3. Billing of contracting agencies for employee/
employer contributions
4. Reports to CalPERS and other state agencies
5. Coordination of benefits among carriers
6. Resolving member appeals, complaints,
or grievances with health plan carriers
Information Disclosure
Portions of this information may be transferred
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
in strict accordance with current statutes
regarding confidentiality.
Your Rights
You have the right to review your membership
files maintained by the System. For questions
about this notice, our Privacy Policy, or your rights,
please write to the CalPERS Privacy Ocer at
400 Q Street, Sacramento, CA 95811 or call us
at 888 CalPERS (or 888-225-7377).
May 2016
Form
W-4
LONG BEACH UNIFIED SCHOOL DISTRICT,
1515 HUGHES WAY, LONG BEACH, CA 90810
EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE
Federal and State
(This Certificate is for income tax withholding purposes only.)
Employer’s Federal ID #95-6001886
State ID #800-9069-9
Your withholding is subject to
review by the IRS.
Step 1:
Enter Personal
Information
(a) First name and middle initial
Last name
(b) Social security number
Address
▶
Does your name match the name on
your social security card? If not, to ensure
you get credit for your earnings, contact SSA
at 800-772-1213 or go to
www.ssa.gov.
City or town, state, and ZIP code
(c) Single or Married filing separately
Married filing jointly (or Qualifying widow(er))
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from
withholding, when to use the online estimator, and privacy.
Step 2
:
Multiple Jobs or
Spouse Works
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works.
The correct amount of withholding depends on income earned from all of these jobs.
Do only one of the following.
(a)
Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or
(b)
Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c)
If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option
is
accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . .
▶
TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income,
including as an independent contractor, use the estimator.
Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most
accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)
Step 3:
Claim
Dependents
If your income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000
▶
$
Multiply the number of other dependents by $500 . . . . .
▶
$
Add the amounts above and enter the total here . . . . . . . . . . . . . . . . . . . . . . .
3
$
Step 4:
a)
Other income (not from jobs). If you want tax withheld for other income you expect
this year that won’t
have withholding, enter the amount of other income here. This may
include interest, dividends, and retirement
income . . . . . . . . . . . . . . . .
b) Deductions. If you expect to claim deductions o
ther than the standard deduction and want to reduce
your withholding, use the Deductions Worksheet on page 3 and enter the result here . . . . . . . .
c) Extra withholding. Enter any additional
tax you want withheld each pay period.
4(a)
$
(Optional)
Other
4(b)
$
Adjustments
4(c)
$
Filing Exempt
To claim exemption from withholding, I certify that I meet both of the conditions stated under “Exemption from
withholding” on page 2 of the General Instructions. Write “Exempt” under 4(c).
Step 5:
Employee’s Withholding Allowance Certificate
State of California
Filing Status Withholding Allowances for the State of California only
SINGLE or MARRIED (with two or more incomes)
MARRIED (one income)
HEAD OF HOUSEHOLD
1.
Total Number of allowances you're claiming (Use Work
sheet A for regular withholding allowances. Use other
worksheets on the following pages as applicable. Worksheet A+B).
2.
Additional amount, if any, you want withheld each pay period (if employer agrees), (Worksheet B and C)
OR
Exemption from Withholding
3.
I claim exemption from withholding for 2020, and I certify I meet both of the conditions of exemption.
Step
6:
Sign
Here
Under the penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct and
complete. I further certify that the number of withholding allowances claimed on this certificate does not exceed the number to
which I am entitled or, if claiming exemption from withholding, that I am entitled to claim the exempt status.
Employee’s signature
(This form is not valid unless you sign it.)
Date
Form W-4 (2020)
Write "Exempt" here
OR
I certify under penalty of perjury that I am not subject to California withholding. I meet the conditions set forth under
the Service Member Civil Relief Act, as amended by the Military Spouses Residency Relief Act and the Veterans
Benefits and Transition Act of 2018.
0.00
You will be able to sign up for Direct Deposit through MyLBUSD Portal,
using the “Employee Self Service” Information Guide, located on the
following four (4) pages once you have been issued a start date and your
assignment is online.
EMPLOYEE SELF SERVICE
You are now able to go online and make changes yourself to
the following:
• Direct Deposit Authorization
• Salary Advance
• W-4 Form
• Change of Address/Contact Information
You can also view or print the following:
• Pay Stubs
• W-2 Form
• Notice of Assignment
• Special Contract Renewal
1
EMPLOYEE SELF SERVICE
2
Step 1:
On the LBUSD webpage www.lbschools.net click on Employees and then select myLBUSD Portal
Once selected you will be routed to the portal login page where you will need to enter your
Username and Password and click on Log In
EMPLOYEE SELF SERVICE
3
Step 2:
Once in the Portal select Applications at the bottom in the middle of the screen
Once on the Applications screen click on the Self Service info box
EMPLOYEE SELF SERVICE
Step 3:
Once on the Employee Self Service Access screen you will see the list of your available options.
Click on the tab of your choice.
4
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

APPLICATION UPDATE FOR CLASSIFIED EMPLOYMENT (Long Beach Unified School District)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 March 2022

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