EMPLOYMENT APPLICATION
THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE AN EMPLOYMENT CONTRACT BETWEEN THE EMPLOYEE AND THE
AGENCY. THIS DOCUMENT DOES NOT CREATE ANY CONTRACTUAL RIGHTS OR ENTITLEMENTS. THE AGENCY RESERVES THE RIGHT
TO REVISE THE CONTENT OF THIS DOCUMENT, IN WHOLE OR IN PART. NO PROMISES OR ASSURANCES, WHETHER WRITTEN OR ORAL,
WHICH ARE CONTRARY TO OR INCONSISTENT WITH THE TERMS OF THIS PARAGRAPH CREATE ANY CONTRACT OF EMPLOYMENT.
Position applying for:
J
ob Title ____________________________________________________________________________________________________________________________
Agency __________________________________________________________________________________________ Location ___________________________
Contact Information
Na
me ___________________________________________________________________________________ Former Last Name ____________________________
First Middle Initial Last
Ma
iling Address ______________________________________________________________________________________________________________________
A
ddress ____________________________________________________________________________________________________________________________
City County State Zip Code
E
mail Address _______________________________________________________________________________________________________________________
Home Phone_________________________________ Alternate Phone _______________________________ Notification Preference Mail Email
Other Personal Information
D
o you possess a valid driver’s license? Yes No If yes, provide State and number: _____________________________________________________________
Expiration date __________________ Class (check one) A B C D E F M G
Can you, after employment, submit proof of your legal right to work in the United States? Yes No
Are you willing to relocate? Yes No If yes, provide counties _____________________________________________________________________
What type of job are you looking for? Regular Temporary Seasonal Internship
What types of work will you accept? Full Time Part Time Per Diem
What shifts are you available to work? Day Evening Night Rotating Weekends On Call (as needed)
Education
H
igh School Name _____________________________________ Location _____________________________ Diploma Other (specify) ______________
G
ive name and address of school, major course of study, and degree achieved.
Undergraduate College/University ____________________________________ Graduate School ___________________________________________________
Degree Attained __________________________________________________ Degree Attained ____________________________________________________
Year ___________________________________________________________ Year _____________________________________________________________
Additional Information
C
ertificates and Licenses ________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
A
dditional Skills ______________________________________________________________________________________________________________________
An Equal Opportunity Employer
EMPLOYMENT APPLICATION
Work History
Describe your work experience in detail, beginning with your current or most recent job. Include military service (indicate rank) and job related volunteer work, if
applicable. Provide explanation for any gaps in employment. All information in this section must be complete. A résumé may be attached, but not substituted for
completing this section. Should you need additional space, copy this page.
1. Name of Present or Last Employer: _____________________________________________________________________________________________________
Job Title: ___________________________________________________________________________________________________________________________
Address: _______________________________________________________________ Phone ____________________ Supervisor _________________________
From: ______ / _______ / ______ To: ______ / ______ / ______ Hours Per Week ________ Salary ______________ Number Supervised ______
May we contact this employer? Yes No
Job Duties (give details) ________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Reason For Leaving ___________________________________________________________________________________________________________________
2. Your Next Most Recent Employer: _____________________________________________________________________________________________________
Job Title: ___________________________________________________________________________________________________________________________
Address: _______________________________________________________________ Phone ____________________ Supervisor _________________________
From: ______ / _______ / ______ To: ______ / ______ / ______ Hours Per Week ________ Salary ______________ Number Supervised ______
May we contact this employer? Yes No
Job Duties (give details) ________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Reason For Leaving ___________________________________________________________________________________________________________________
3. Your Next Most Recent Employer: _____________________________________________________________________________________________________
Job Title: ___________________________________________________________________________________________________________________________
Address: _______________________________________________________________ Phone ____________________ Supervisor _________________________
From: ______ / _______ / ______ To: ______ / ______ / ______ Hours Per Week ________ Salary ______________ Number Supervised ______
May we contact this employer? Yes No
Job Duties (give details) ________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Reason For Leaving____________________________________________________________________________________________________________________
EMPLOYMENT APPLICATION
Please carefully read the following information:
Have you ever been convicted of a criminal offense? Yes No
Note: Omit minor vehicle violations and any offense committed before your 17th birthday which was finally adjudicated in juvenile court or under a youthful offender
law. Conviction of a criminal offense is not necessarily an absolute bar to state government employment in all cases. Each conviction is evaluated individually.
If yes, please list charge(s) _________________________________________________________________________________________________________
Where Convicted____________________________________________________ Date _____________ Disposition/Status ____________________________
Are you currently employed by the State of South Carolina? Yes No If yes, which agency?_________________________________________________
Do you have any relatives employed with the State of South Carolina? Yes No If yes, please provide name(s), relationship, and agency below.
Name _____________________________________ Relationship ______________________ Agency _____________________________________________
Name _____________________________________ Relationship ______________________ Agency _____________________________________________
Have you ever been terminated or forced to resign from any job? Yes No If yes, please explain below.
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Have you been separated from South Carolina State Government employment as a part of a reduction-in-force within the past 12 months? Yes No
Give the name, address, and phone number of two people, not relatives, who are familiar with your work.
Name ___________________________________________ Address __________________________________________________ Phone ____________________
Name ___________________________________________ Address __________________________________________________ Phone ____________________
Student Loan: State Law (59-111-50) prohibits employment with the State to people who have defaulted on certain student loans, unless they can prove that satisfactory
arrangements have been made for repayment. By my signature, I certify that I am not currently in default on a student loan.
Signature _____________________________________________________ Date ______________________________
Authority to Release Information: By my signature, I consent to the release of information to authorized officers, agents, and employees of the State of South Carolina
which may include but not be limited to information concerning my past and present work; including my official personnel files; attendance records; evaluations;
educational records including transcripts; military service; law enforcement records; and any personnel record deemed necessary. In addition, I consent to authorize
appropriate officers, agents and employees of the State to make inquiries of third parties. I further release the organization, educational entity, present and former
employers, law enforcement organization, all third parties from any and all claims of whatever nature that I may have as a result of any inquiry or response given to
such inquiries made in connection with my application for employment.
Signature _____________________________________________________ Date ______________________________
Certification of Applicant: By my signature, I affirm, agree, and understand that all statements on this form are true and accurate. Any misrepresentation, falsification,
or material omission of information or data on this application may result in exclusion from further consideration or, if hired, termination of employment. If I have
requested herein that my present employer not be contacted, an offer of employment may be conditioned upon acceptable information and verification from such
employer prior to beginning work.
Signature _____________________________________________________ Date ______________________________
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EMPLOYMENT APPLICATION
The following questions are strictly voluntary and will provide us with statistics needed to evaluate our
recruitment program, as well as prepare statistical reports required by Federal, State, and local agencies.
This information is not forwarded to hiring authorities.
GENDER
o Female
o Male
ETHNICITY
o American Indian/Alaska Native
o Asian
o Black/African American
o Hispanic/Latino
o Native Hawaiian/Other Pacific Islander
o Two or More Races
o White
DATE OF BIRTH
_______ / ________ / _________
Form W-4 (2019)
Future developments. For the latest
information about any future developments
related to Form W-4, such as legislation
enacted after it was published, go to
www.irs.gov/FormW4.
Purpose. Complete Form W-4 so that your
employer can withhold the correct federal
income tax from your pay. Consider
completing a new Form W-4 each year and
when your personal or financial situation
changes.
Exemption from withholding. You may
claim exemption from withholding for 2019
if both of the following apply.
• For 2018 you had a right to a refund of all
federal income tax withheld because you
had no tax liability, and
• For 2019 you expect a refund of all
federal income tax withheld because you
expect to have no tax liability.
If you’re exempt, complete only lines 1, 2,
3, 4, and 7 and sign the form to validate it.
Your exemption for 2019 expires February
17, 2020. See Pub. 505, Tax Withholding
and Estimated Tax, to learn more about
whether you qualify for exemption from
withholding.
General Instructions
If you aren’t exempt, follow the rest of
these instructions to determine the number
of withholding allowances you should claim
for withholding for 2019 and any additional
amount of tax to have withheld. For regular
wages, withholding must be based on
allowances you claimed and may not be a
flat amount or percentage of wages.
You can also use the calculator at
www.irs.gov/W4App to determine your
tax withholding more accurately. Consider
using this calculator if you have a more
complicated tax situation, such as if you
have a working spouse, more than one job,
or a large amount of nonwage income not
subject to withholding outside of your job.
After your Form W-4 takes effect, you can
also use this calculator to see how the
amount of tax you’re having withheld
compares to your projected total tax for
2019. If you use the calculator, you don’t
need to complete any of the worksheets for
Form W-4.
Note that if you have too much tax
withheld, you will receive a refund when you
file your tax return. If you have too little tax
withheld, you will owe tax when you file your
tax return, and you might owe a penalty.
Filers with multiple jobs or working
spouses. If you have more than one job at
a time, or if you’re married filing jointly and
your spouse is also working, read all of the
instructions including the instructions for
the Two-Earners/Multiple Jobs Worksheet
before beginning.
Nonwage income. If you have a large
amount of nonwage income not subject to
withholding, such as interest or dividends,
consider making estimated tax payments
using Form 1040-ES, Estimated Tax for
Individuals. Otherwise, you might owe
additional tax. Or, you can use the
Deductions, Adjustments, and Additional
Income Worksheet on page 3 or the
calculator at www.irs.gov/W4App to make
sure you have enough tax withheld from
your paycheck. If you have pension or
annuity income, see Pub. 505 or use the
calculator at www.irs.gov/W4App to find
out if you should adjust your withholding
on Form W-4 or W-4P.
Nonresident alien. If you’re a nonresident
alien, see Notice 1392, Supplemental Form
W-4 Instructions for Nonresident Aliens,
before completing this form.
Specific Instructions
Personal Allowances Worksheet
Complete this worksheet on page 3 first to
determine the number of withholding
allowances to claim.
Line C. Head of household please note:
Generally, you may claim head of household
filing status on your tax return only if you’re
unmarried and pay more than 50% of the
costs of keeping up a home for yourself and
a qualifying individual. See Pub. 501 for
more information about filing status.
Line E. Child tax credit. When you file your
tax return, you may be eligible to claim a
child tax credit for each of your eligible
children. To qualify, the child must be under
age 17 as of December 31, must be your
dependent who lives with you for more than
half the year, and must have a valid social
security number. To learn more about this
credit, see Pub. 972, Child Tax Credit. To
reduce the tax withheld from your pay by
taking this credit into account, follow the
instructions on line E of the worksheet. On
the worksheet you will be asked about your
total income. For this purpose, total income
includes all of your wages and other
income, including income earned by a
spouse if you are filing a joint return.
Line F. Credit for other dependents.
When you file your tax return, you may be
eligible to claim a credit for other
dependents for whom a child tax credit
can’t be claimed, such as a qualifying child
who doesn’t meet the age or social
security number requirement for the child
tax credit, or a qualifying relative. To learn
more about this credit, see Pub. 972. To
reduce the tax withheld from your pay by
taking this credit into account, follow the
instructions on line F of the worksheet. On
the worksheet, you will be asked about
your total income. For this purpose, total
Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.
Form W-4
Department of the Treasury
Internal Revenue Service
Employee’s Withholding Allowance Certificate
a
Whether you’re entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
OMB No. 1545-0074
2019
1 Your first name and middle initial Last name
Home address (number and street or rural route)
City or town, state, and ZIP code
2 Your social security number
3
Single Married Married, but withhold at higher Single rate.
Note: If married filing separately, check “Married, but withhold at higher Single rate.”
4
If your last name differs from that shown on your social security card,
check here. You must call 800-772-1213 for a replacement card.
a
5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) .... 5
6 Additional amount, if any, you want withheld from each paycheck .............. 6
$
7 I claim exemption from withholding for 2019, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . ..............
a
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.)
a
Date
a
8 Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete
boxes 8, 9, and 10 if sending to State Directory of New Hires.)
9 First date of
employment
10 Employer identification
number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 4.
Cat. No. 10220Q
Form W-4 (2019)
Form W-4 (2019)
Page 2
income includes all of your wages and
other income, including income earned by
a spouse if you are filing a joint return.
Line G. Other credits. You may be able to
reduce the tax withheld from your
paycheck if you expect to claim other tax
credits, such as tax credits for education
(see Pub. 970). If you do so, your paycheck
will be larger, but the amount of any refund
that you receive when you file your tax
return will be smaller. Follow the
instructions for Worksheet 1-6 in Pub. 505
if you want to reduce your withholding to
take these credits into account. Enter “-0-”
on lines E and F if you use Worksheet 1-6.
Deductions, Adjustments, and
Additional Income Worksheet
Complete this worksheet to determine if
you’re able to reduce the tax withheld from
your paycheck to account for your itemized
deductions and other adjustments to
income, such as IRA contributions. If you
do so, your refund at the end of the year
will be smaller, but your paycheck will be
larger. You’re not required to complete this
worksheet or reduce your withholding if
you don’t wish to do so.
You can also use this worksheet to figure
out how much to increase the tax withheld
from your paycheck if you have a large
amount of nonwage income not subject to
withholding, such as interest or dividends.
Another option is to take these items into
account and make your withholding more
accurate by using the calculator at
www.irs.gov/W4App. If you use the
calculator, you don’t need to complete any
of the worksheets for Form W-4.
Two-Earners/Multiple Jobs
Worksheet
Complete this worksheet if you have more
than one job at a time or are married filing
jointly and have a working spouse. If you
don’t complete this worksheet, you might
have too little tax withheld. If so, you will
owe tax when you file your tax return and
might be subject to a penalty.
Figure the total number of allowances
you’re entitled to claim and any additional
amount of tax to withhold on all jobs using
worksheets from only one Form W-4. Claim
all allowances on the W-4 that you or your
spouse file for the highest paying job in
your family and claim zero allowances on
Forms W-4 filed for all other jobs. For
example, if you earn $60,000 per year and
your spouse earns $20,000, you should
complete the worksheets to determine
what to enter on lines 5 and 6 of your Form
W-4, and your spouse should enter zero
(“-0-”) on lines 5 and 6 of his or her Form
W-4. See Pub. 505 for details.
Another option is to use the calculator at
www.irs.gov/W4App to make your
withholding more accurate.
Tip: If you have a working spouse and your
incomes are similar, you can check the
“Married, but withhold at higher Single
rate” box instead of using this worksheet. If
you choose this option, then each spouse
should fill out the Personal Allowances
Worksheet and check the “Married, but
withhold at higher Single rate” box on Form
W-4, but only one spouse should claim any
allowances for credits or fill out the
Deductions, Adjustments, and Additional
Income Worksheet.
Instructions for Employer
Employees, do not complete box 8, 9, or
10. Your employer will complete these
boxes if necessary.
New hire reporting. Employers are
required by law to report new employees to
a designated State Directory of New Hires.
Employers may use Form W-4, boxes 8, 9,
and 10 to comply with the new hire
reporting requirement for a newly hired
employee. A newly hired employee is an
employee who hasn’t previously been
employed by the employer, or who was
previously employed by the employer but
has been separated from such prior
employment for at least 60 consecutive
days. Employers should contact the
appropriate State Directory of New Hires to
find out how to submit a copy of the
completed Form W-4. For information and
links to each designated State Directory of
New Hires (including for U.S. territories), go
to www.acf.hhs.gov/css/employers.
If an employer is sending a copy of Form
W-4 to a designated State Directory of
New Hires to comply with the new hire
reporting requirement for a newly hired
employee, complete boxes 8, 9, and 10 as
follows.
Box 8. Enter the employer’s name and
address. If the employer is sending a copy
of this form to a State Directory of New
Hires, enter the address where child
support agencies should send income
withholding orders.
Box 9. If the employer is sending a copy of
this form to a State Directory of New Hires,
enter the employee’s first date of
employment, which is the date services for
payment were first performed by the
employee. If the employer rehired the
employee after the employee had been
separated from the employer’s service for
at least 60 days, enter the rehire date.
Box 10. Enter the employer’s employer
identification number (EIN).
Form W-4 (2019)
Page 3
Personal Allowances Worksheet (Keep for your records.)
A Enter “1” for yourself .............................. A
B Enter “1” if you will file as married filing jointly ....................... B
C Enter “1” if you will file as head of household ....................... C
D Enter “1” if:
{
• You’re single, or married filing separately, and have only one job; or
• You’re married filing jointly, have only one job, and your spouse doesn’t work; or
• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
}
D
E Child tax credit. See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “4” for each eligible child.
• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “2” for each
eligible child.
• If your total income will be from $179,051 to $200,000 ($345,851 to $400,000 if married filing jointly), enter “1” for
each eligible child.
• If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter “-0-” .......
E
F Credit for other dependents. See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “1” for each eligible dependent.
• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “1” for every
two dependents (for example, “-0-” for one dependent, “1” if you have two or three dependents, and “2” if you have
four dependents).
• If your total income will be higher than $179,050 ($345,850 if married filing jointly), enter “-0-” .......
F
G Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet
here. If you use Worksheet 1-6, enter “-0-” on lines E and F ..................
G
H Add lines A through G and enter the total here ......................
a
H
For accuracy,
complete all
worksheets
that apply.
{
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you
have a large amount of nonwage income not subject to withholding and want to increase your withholding,
see the Deductions, Adjustments, and Additional Income Worksheet below.
• If you have more than one job at a time or are married filing jointly and you and your spouse both
work, and the combined earnings from all jobs exceed $53,000 ($24,450 if married filing jointly), see the
Two-Earners/Multiple Jobs Worksheet on page 4 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 above.
Deductions, Adjustments, and Additional Income Worksheet
Note: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of nonwage
income not subject to withholding.
1
Enter an estimate of your 2019 itemized deductions. These include qualifying home mortgage interest,
charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 10% of
your income. See Pub. 505 for details ...................... 1
$
2 Enter:
{
$24,400 if you’re married filing jointly or qualifying widow(er)
$18,350 if you’re head of household
$12,200 if you’re single or married filing separately
}
........... 2
$
3 Subtract line 2 from line 1. If zero or less, enter “-0-” ................. 3
$
4 Enter an estimate of your 2019 adjustments to income, qualified business income deduction, and any
additional standard deduction for age or blindness (see Pub. 505 for information about these items) . .
4
$
5 Add lines 3 and 4 and enter the total ...................... 5
$
6 Enter an estimate of your 2019 nonwage income not subject to withholding (such as dividends or interest) . 6
$
7 Subtract line 6 from line 5. If zero, enter “-0-”. If less than zero, enter the amount in parentheses . . . 7
$
8 Divide the amount on line 7 by $4,200 and enter the result here. If a negative amount, enter in parentheses.
Drop any fraction ............................
8
9 Enter the number from the Personal Allowances Worksheet, line H, above .......... 9
10
Add lines 8 and 9 and enter the total here. If zero or less, enter “-0-”. If you plan to use the Two-Earners/
Multiple Jobs Worksheet, also enter this total on line 1 of that worksheet on page 4. Otherwise, stop here
and enter this total on Form W-4, line 5, page 1 ...................
10
Form W-4 (2019)
Page 4
Two-Earners/Multiple Jobs Worksheet
Note: Use this worksheet only if the instructions under line H from the Personal Allowances Worksheet direct you here.
1
Enter the number from the Personal Allowances Worksheet, line H, page 3 (or, if you used the
Deductions, Adjustments, and Additional Income Worksheet on page 3, the number from line 10 of that
worksheet) .............................. 1
2
Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you’re
married filing jointly and wages from the highest paying job are $75,000 or less and the combined wages for
you and your spouse are $107,000 or less, don’t enter more than “3” .............
2
3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”)
and on Form W-4, line 5, page 1. Do not use the rest of this worksheet ............
3
Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to
figure the additional withholding amount necessary to avoid a year-end tax bill.
4 Enter the number from line 2 of this worksheet ........... 4
5 Enter the number from line 1 of this worksheet ........... 5
6 Subtract line 5 from line 4 .......................... 6
7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here ..... 7
$
8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . . 8
$
9
Divide line 8 by the number of pay periods remaining in 2019. For example, divide by 18 if you’re paid every
2 weeks and you complete this form on a date in late April when there are 18 pay periods remaining in
2019. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld
from each paycheck ...........................
9
$
Table 1
Married Filing Jointly
If wages from LOWEST
paying job are—
Enter on
line 2 above
$0 - $5,000 0
5,001 - 9,500 1
9,501 - 19,500 2
19,501 - 35,000 3
35,001 - 40,000 4
40,001 - 46,000 5
46,001 - 55,000 6
55,001 - 60,000 7
60,001 - 70,000 8
70,001 - 75,000 9
75,001 - 85,000 10
85,001 - 95,000 11
95,001 - 125,000 12
125,001 - 155,000 13
155,001 - 165,000 14
165,001 - 175,000 15
175,001 - 180,000 16
180,001 - 195,000 17
195,001 - 205,000 18
205,001
and over
19
All Others
If wages from LOWEST
paying job are—
Enter on
line 2 above
$0 - $7,000 0
7,001 - 13,000 1
13,001 - 27,500 2
27,501 - 32,000 3
32,001 - 40,000 4
40,001 - 60,000 5
60,001 - 75,000 6
75,001 - 85,000 7
85,001 - 95,000 8
95,001 - 100,000 9
100,001 - 110,000 10
110,001 - 115,000 11
115,001 - 125,000 12
125,001 - 135,000 13
135,001 - 145,000 14
145,001 - 160,000 15
160,001 - 180,000 16
180,001 and over 17
Table 2
Married Filing Jointly
If wages from HIGHEST
paying job are—
Enter on
line 7 above
$0 - $24,900 $420
24,901 - 84,450 500
84,451 - 173,900 910
173,901 - 326,950 1,000
326,951 - 413,700 1,330
413,701 - 617,850 1,450
617,851
and over
1,540
All Others
If wages from HIGHEST
paying job are—
Enter on
line 7 above
$0 - $7,200 $420
7,201 - 36,975 500
36,976 - 81,700 910
81,701 - 158,225 1,000
158,226 - 201,600 1,330
201,601 - 507,800 1,450
507,801 and over 1,540
Privacy Act and Paperwork Reduction
Act Notice. We ask for the information on
this form to carry out the Internal Revenue
laws of the United States. Internal Revenue
Code sections 3402(f)(2) and 6109 and
their regulations require you to provide this
information; your employer uses it to
determine your federal income tax
withholding. Failure to provide a properly
completed form will result in your being
treated as a single person who claims no
withholding allowances; providing
fraudulent information may subject you to
penalties. Routine uses of this information
include giving it to the Department of
Justice for civil and criminal litigation; to
cities, states, the District of Columbia, and
U.S. commonwealths and possessions for
use in administering their tax laws; and to
the Department of Health and Human
Services for use in the National Directory of
New Hires. We may also disclose this
information to other countries under a tax
treaty, to federal and state agencies to
enforce federal nontax criminal laws, or to
federal law enforcement and intelligence
agencies to combat terrorism.
You aren’t required to provide the
information requested on a form that’s
subject to the Paperwork Reduction Act
unless the form displays a valid OMB
control number. Books or records relating
to a form or its instructions must be
retained as long as their contents may
become material in the administration of
any Internal Revenue law. Generally, tax
returns and return information are
confidential, as required by Code section
6103.
The average time and expenses required
to complete and file this form will vary
depending on individual circumstances.
For estimated averages, see the
instructions for your income tax return.
If you have suggestions for making this
form simpler, we would be happy to hear
from you. See the instructions for your
income tax return.
USCIS
Form I-9
OMB No. 1615-0047
Expires 08/31/2019
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 11/14/2016 N
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)
U.S. Social Security Number
-
-
Employee's E-mail Address
Employee's Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
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.
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 11/14/2016 N
Page 2 of 3
USCIS
Form I-9
OMB No. 1615-0047
Expires 08/31/2019
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)
Signature of Employer or Authorized Representative
Today's Date(mm/dd/yyyy)
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative
Employer's Business or Organization Name
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
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
8. 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 Birth Abroad issued
by the Department of State (Form
FS-545)
3. Certification of Report of Birth
issued by the Department of State
(Form DS-1350)
4. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
5. Native American tribal document
7. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
6. 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 11/14/2016 N
Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
S2VERIFY‐CONFIDENTIAL 1| 3.2.16version‐credit
ApplicantDisclosureStatement
InconnectionwithyourapplicationwithYorkTechnicalCollegeyoumayhaveinformationrequestedaboutyoufroma
consumerreportingagencyassuchtermisusedwithinTheFairCreditReportingAct15U.S.C.§1681forthepurpose
ofdeterminingyourqualificationforemployment,includingacriminalbackgroundcheck.Thisinformationmay
beobtainedintheformofconsumerreports.
Thesereportsmaycontaininformationaboutyourcharacter,generalreputation,personalcharacteristicsand/ormode
ofliving.Thetypesofinformationthatmaybeobtainedinclude,butarenotlimitedto:socialsecuritynumber
verifications;addresshistory;criminalrecordschecks;publiccourtrecordschecks;andprofessional
licensing/certificationchecks.Thisinformationmaybeobtainedfrompublicrecordssources,including,asappropriate,
governmentalagenciesandcourthouses;educationalinstitutions;formeremployers;orotherinformationsources.
Ifadverseactionistakenfrominformationobtained,inwholeorinpart,fromaconsumerreportfromaconsumer
reportingagency,youhavetherighttoreceiveacopyofthereport(s)fromtheconsumerreportingagency.Theconsumer
reportingagencywhichpreparedtheconsumerreportwasS2Verify,LLC.S2Verify,LLCcanbecontactedatP.O.Box
2597,Roswell,GA30077orbyphoneat(770)649‐8282orbyemailatcompliance@s2verify.com.
[EndofDisclosureStatement]
S2VERIFY‐CONFIDENTIAL 2| 3.2.16version‐credit
AuthorizationofBackgroundInvestigation
I
havecarefullyread,andunderstand,thisAuthorizationformandfurtheracknowledgereceiptoftheseparatedocument
entitled ASummaryofYour RightsundertheFairCreditReportingAct” (available at
http://www.S2Verify.com/resources.html orasahardcopyprovidedbytheDEPARTMENT
) andthe“Applicant
DisclosureStatement”andcertifythatIhavereadandunderstandbothdocuments.Bymysignaturebelow,Iconsent
tothereleaseofconsumerreports(“BackgroundReports”)preparedbyaconsumerreportingagency,suchasS2Verify,
LLC.,orotherconsumerreportingagencyatitsrequesttoYorkTechnicalCollegeanditsdesignatedrepresentativesand
agentsforthepurposeofdetermining my qualification for employment with the DEPARTMENT, or other lawful
purposes.
I understand that if York Technical College engages in a relationshipwithme,myconsentwillapply,andthe
DEPARTMENTmayobtainBackgroundReportsthroughoutmyrelationshipwiththem,ifsuchobtainmentispermissible
underapplicableStatelawandYorkTechnicalCollegepolicy.
I also understand that information contained in my
application,orotherwisedisclosedbymemaybeusedwhenorderingtheBackgroundReportsandthatnothingherein
shallbeconstruedasaguaranteeofarelationshipwithYorkTechnicalCollege
Iherebyauthorizelawenforcementagenciesinformationservicebureaus,consumerreportingagencies,record/data
repositories,courts(federal,state,andlocal),motorvehiclerecordsagencies,,themilitary,andotherinformationsources
tofurnishany,andall,informationonmethatisrequestedbytheconsumerreportingagency.
YorkTechnicalCollegeisrequestingcreditinformationforthefollowingreasons:Todeterminemyqualificationfor
employment,includingbutnotlimitedtoacriminalbackgroundcheck.
CaliforniaApplicantsOnly:IacknowledgereceiptofacopyofCaliforniaCivilCode1786.22.PursuanttoSection
1786.22oftheCaliforniaCivilCode,youmayviewthefilemaintainedonyoubyS2Verifyduringnormalbusinesshours.
Youmayalsoobtainacopyofthisfile,uponsubmittingproperidentificationbyappearingatS2Verify'sofficesinperson,
duringnormalbusinesshoursandonreasonablenotice,orbymail. You may also receive a summary of the file by
telephone,uponsubmittingproperidentification.S2Verifyhastrainedpersonnelavailabletoexplainyourfiletoyou,
includinganycodedinformation.Bysigningbelow,youacknowledgereceiptofCaliforniaCivilCode1786.22,available
athttp://www.S2Verify.com/resources.html.
NewYorkApp
licantsOnly:IacknowledgereceiptofacopyofArticle23AofNewYorkCorrectionLaw.
Bysigningbelow,youacknowledgereceiptofArticle23Aofthe New York Correction Law, available at
http://www.S2Verify.com/resources.html.
{SignatureLineAppearsonNextPage}
California,MinnesotaorOklahomaapplicantsonly:
Youmayreceiveafreecopyofanyconsumerreportorinvestigativeconsumerreportobtainedonyouifyoucheck
theboxbelow.
Iwishtoreceiveafreecopyofthereport.
S2VERIFY‐CONFIDENTIAL3|3.2.16version‐credit
Bymysignaturebelow,IcertifytheinformationIprovidedon,andinconnectionwith,thisformistrue,accurate,and
complete. I agreethatthisAuthorizationformin original,facsimile, photocopy,or electronic(including electronically
signed)formats,willbevalidforanyreportsthatmayberequestedby,oronbehalfofYorkTechnicalCollege.
FirstName:_________________________________MiddleInitial_________LastName:_____________________________________
Address:________________________________________________________________________________________________________________
City:_________________________________________________________State:_______________________________Zip:_________________
SocialSecurityNumber:_____________________________________________DateofBirth:__________________________________
DriversLicenseNumber________________________________________________StateofIssue_____________________________
EmailAddress:____________________________________________
Signature:_____________________________________________________________Date:_________________________________________
AdditionalStateLawNotices
California,OklahomaandMinnesota:Youhavetherighttoreceiveacopyofyourbackground/investigativereportby
checkingtheboxontheAuthorizationofBackgroundInvestigationform.
Massachusetts and NewJersey:Ifwerequestaninvestigativebackgroundreport,youhavetheright,uponwritten
request,toacopyofthereport.
MinnesotaandWashingtonState:IfYorkTechnicalCollegerequestsaninvestigativebackgroundreport,youhavethe
right,uponwrittenrequestmadewithinareasonableperiodoftimeafteryourreceiptofthisdisclosure,toreceivefrom
the DEPARTMENTa completeand accuratedisclosure ofthe nature and scope of theinvestigation requested by the
DEPARTMENT.TheDEPARTMENTwillprovidethedisclosureofthenatureandscopeoftheinvestigationeitherfivedays
afterreceivingyourrequestorafterrequestingtheinvestigativeconsumerreport,whicheverislater.
NewYorkApplicantsOnly:YouhavetherighttorequestwhetherYorkTechnicalCollegerequestedaninvestigative
consumerreportand,ifso,YorkTechnicalCollegewillgiveyouthenameandaddressofthereportsproviderifother
thantheconsumerreportingagencyidentifiedabove.Youhavetherighttoinspectandreceiveacopyofanyinvestigative
consumerreportrequestedbyYorkTechnicalCollegebycontactingtheconsumerreportingagencyidentifiedabove(or
anotherorganizationidentifiedbyYorkTechnicalCollegeastheproviderofaninvestigativeconsumerreport)directly.
WashingtonState:Youalsohavetherighttorequestfromtheconsumerreportingagencyawrittensummaryofyour
rightsand
remediesundertheWashingtonFairCreditReportingAct.
CREDITREPORTS:
California,Colorado, Connecticut,Hawaii,Illinois,Maryland, Nevada, Oregon, Vermont, and Washington State:
ThelistedstatesrestrictthecircumstancesinwhichYorkTechnicalCollegemayobtaincreditinformationaboutyou.
YorkTechnicalCollegewillnotobtaincreditinformationaboutyouunlesssuchinformationissubstantiallyrelatedto
thedutiesandresponsibilitiesofthepositionforwhichyouareapplyingorforanyotherreasonotherwisepermitted
underapplicablelaw.
S2VERIFY‐CONFIDENTIAL 4| 3.2.16version‐credit
*PleaseNote:
a)
S2Verifydoesnotprovidelegaladvice.Thedisclosureandauthorizationformisprovidedsolelyas
anexampleorillustration,anditshouldbemodifiedandusedinaccordancewithyourestablished
business and compliance requirements. Finally, please ensure your legal counsel or compliance
officerreviewswhateverformsyoudecidetoutilizeandorde
ploy.
b)
The Federal Trade Commission has opined that “employment purposes” includes volunteer and
independentcontractorrelationshipsbetweencompaniesandindividuals.
Direct Deposit Agreement Form
Authorization Agreement
I hereby authorize
York Technical College to initiate automatic deposits to my account at the financial
institution named below. I also authorize
York Technical College to make withdrawals from this account in
the event that a credit entry is made in
error. I realize that I will not be issued a pay advice, but will be given
access via
Web Advisor where I may view my payroll history.
Further, I agree not to hold
York Technical College responsible for any delay or loss of funds due to
incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part
of my financial institution in depositing funds to my account.
This agreement will remain in effect until
York Technical College receives a written notice of cancellation
from me or my financial institution, or until I submit a new direct deposit form to the Payroll Department.
Account Information
Name of Financial Institution:
Routing Number:
(Bottom of check)
Account Number:
(Bottom of check)
Checking
Savings
Signature
Authorized Signature :
Date:
Printed Name
Please attach a VOIDED CHECK and return this form to the Payroll Department.
Direct Deposit forms must be received by the 15
the
of any month in order to be deposited into your
account the
following month. Please call the Payroll Department, 803-981-7022, with questions, or concerns.
CID #
Payroll use only:
Date keyed:
Date effective:
Form 1104
Revised 8/28/2012
Page 1
ELECTION OF NON-MEMBERSHIP
SC Public Employee Benefit Authority
South Carolina Retirement Systems
Attention: Enrollment
Box 11960, Columbia, SC 29211-1960
4. Address
SECTION I
3. Social Security Number
7. ZIP+4
1. Last Name & Suffix
(PLEASE PRINT) 2. First/Middle Name (PLEASE PRINT)
EMPLOYEE INFORMATION
I understand that an employee hired by an eligible employer (school district, higher education, technical college, state department, agency,
bureau, commission, and institution) covered under the South Carolina Retirement System (SCRS), who is not receiving benefits as a retired
member, may elect to participate in either the traditional defined benefit plan, SCRS, or the optional defined contribution plan, State ORP. The
election to participate in State ORP must be made within 30 calendar days after entry into service (date of hire).
I hereby notify you that I am an employee of the state of South Carolina or its political subdivisions, and that I meet the requirements to elect
non-membership in the Retirement Systems, and I hereby exercise my option to elect non-membership.
I take this action under the provisions of the Retirement Act with full knowledge that I will not be credited with retirement service for this period
of employment since I have elected non-membership.
I also certify that the information provided in items 1-12 of Section I of this form are true to the best of my knowledge and belief.
8. Sex
9. Date of Birth
10. Date of Employment
11. Position Title
12. Present Monthly Salary
5. City
THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE ANY CONTRACTUAL RIGHTS OR ENTITLEMENTS AND DOES
NOT CREATE A CONTRACT BETWEEN THE MEMBER AND THE SOUTH CAROLINA RETIREMENT SYSTEMS. THE SOUTH
CAROLINA RETIREMENT SYSTEMS RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT.
Work Telephone: Title:
Employer Name: Employer Code:
Employee Signature:
Employer Signature:
Date:
Date:
Please call SC Retirement Systems Customer Service with any questions: (800) 868-9002 (in state) or (803) 737-6800
SCRS PORS GARS
Print or type in black ink and sign in blue
ink. Please read the instructions on Page 2
before completing this form.
SECTION III
CATEGORY (SEE DESCRIPTIONS ON PAGE 2)
EMPLOYMENT CATEGORY (TO BE COMPLETED BY THE EMPLOYER)
6. State
If the employee's position qualifies him or her to elect non-membership, please mark the appropriate box. If an employee currently has funds on
deposit in the Retirement Systems, the employee may not elect non-membership.
I hereby certify that the employee listed in items 1-2 of Section I of this form meets the requirements to elect non-membership.
Non-Permanent Position
Optional Membership - Exemptions Authorized by the Retirement Act
Elected Official Earning $9,000 or less per Year
Employee Earning Less than $2,000 and working fewer than 1,600 hours in a Year
Active General Assembly Member retired under JSRS or receiving GARS benefits at age 70 or after 30 years service
If you currently have funds on deposit in the Retirement Systems, you may not elect non-membership.
Retired Justice/Judge returning to work for public institution of education
SECTION II
EMPLOYEE CERTIFICATION AND SIGNATURE
M
F
Form 1104 INSTRUCTIONS
Revised 8/28/2012
Page 2
SECTION I - THE EMPLOYEE COMPLETES THIS SECTION.
Complete items 1-12 by providing the requested information.
SECTION II - THE EMPLOYEE COMPLETES THIS SECTION.
Read carefully the statements in this section, then sign and date the form in the spaces provided.
SECTION III - THE EMPLOYER COMPLETES THIS SECTION.
If the employee's position qualifies him or her to elect non-membership, please indicate the appropriate box in Section III. If an
employee currently has funds on deposit in the Retirement Systems, the employee may not elect non-membership. Also indicate
the name and the title of the employer representative who completed the form, that individual's work telephone number, and the
date the form was completed.
An individual may elect non-membership provided he or she does not have funds on deposit in the Retirement Systems and is
filling a position in one of the categories listed on page 1 and described in further detail below.
EMPLOYMENT CATEGORY
Non-Permanent Position: The employee is employed in connection with any program or activity that is of a non-permanent
nature. If the position is permanent, the employee is required to participate. Temporary employees have the option to elect non-
membership. Substitute teachers and public school bus drivers are examples of approved non-permanent positions. Individuals
who are retired from SCRS or PORS may not elect non-membership.
Optional Membership - Exemptions Authorized by the Retirement Act: Positions approved are: day laborers; non-state local
hospital nursing service, medical technicians, housekeeping, dietary, and laundry personnel employed by an employer that
came under SCRS by application; individuals employed on the date of admission for new coverage groups (SCRS or PORS);
individuals having a monthly compensation from public funds of $100.00 or less per month; and state employees required to
participate in the federal railroad retirement system. Within this category "individuals employed on the date of admission for new
coverage groups (SCRS or PORS)" is the only exemption applicable to PORS.
Elected Official Earning $9,000 or less per Year: This individual must not be a full-time employee and must have been elected
to office.
Earning less than $2,000 and Working fewer than 1,600 Hours in a Year: To be eligible for PORS, the law requires that an
individual work a minimum of 1,600 hours and earn $2,000 per year. This individual must join SCRS if he or she does not meet
the qualifications for PORS, unless the individual meets an exemption under SCRS as specified in Section III. Retired PORS
members may not elect non-membership or join SCRS.
Active General Assembly Member: A retired member of JSRS that is elected to the General Assembly, may elect to become a
non-member of GARS. An active member of the General Assembly that is receiving benefits at 70 years of age or after 30 years
service may elect not to become an active member in GARS.
Retired Justice or Judge: A retired member of JSRS that returns to work for a public institution of education may elect non-
membership in SCRS.
Forms not properly completed will be returned to the employer. If the Retirement Systems determines that an individual is not
eligible for non-member status, the employer will be notified.
This information does not cover all areas of non-membership. For more information, please contact Customer Services at
(800) 868-9002 (available within SC only), (803) 737-6800, or cs@retirement.sc.gov . The Retirement Systems Employer
Manual includes more information as well and is available at the Retirement Systems website at www.retirement.sc.gov or by
contacting Customer Services.
(ATTACH LEGAL DOCUMENT INDICATING NAME CHANGE)
(Required only when signed by mark)
25. I hereby certify that the employee listed in Section I of this form is eligible for the retirement plan selected.
16. Select ORP Vendor
1. Last Name & Suffix 3. Social Security Number
(ATTACH A
COPY OF YOUR SOCIAL SECURITY CARD.)
SECTION I: EMPLOYEE INFORMATION (TO BE COMPLETED BY THE EMPLOYEE)
Form 1100
Revised 09/28/2009
Page 1
Print or type in black ink
and sign in blue ink.
Please read the
instructions on Page 2
before completing this
form.
5. City 7. ZIP+4
8. Sex 9. Date of Birth
SECTION II: EMPLOYER INFORMATION (TO BE COMPLETED BY THE EMPLOYER)
A COPY OF THE EMPLOYEE'S SOCIAL SECURITY CARD MUST BE ATTACHED TO THIS FORM TO ENROLL THE MEMBER. THE NAME ON
THE SOCIAL SECURITY CARD MUST MATCH THE NAME LISTED IN ITEMS 1-2 IN SECTION I OF THIS FORM.
19. Employer Name
20. Please indicate if you are the employee's primary or secondary
employer. (Annual member statements are sent to primary employers for
distribution to members.)
24. Employee's Annual Salary
23. Employee's Position Title22. Date of Membership
10. Telephone Number
17. An employee hired by an eligible employer (school district, higher education, technical college, state department, agency, bureau,
commission, and institution) covered under the South Carolina Retirement System (SCRS), may elect to participate in either the traditional
defined benefit plan, SCRS, or the optional defined contribution plan, State ORP. The election to participate in State ORP must be made
within 30 calendar days after entry into service (date of hire).
If I do not make an election within the required time, I will be considered to have elected membership in SCRS. Participants in the State
ORP assume all investment risk. The election to participate in State ORP is irrevocable, except a State ORP participant may make a one-
time irrevocable election to join SCRS during any open enrollment period after the first annual anniversary, but before the fifth annual
anniversary of the initial enrollment in State ORP.
I understand that, unless a designated beneficiary is on file, my estate will be designated as my beneficiary until the Retirement Systems
receives from me a properly executed beneficiary form.
My signature below indicates that my employer has explained the retirement plan options available to me and has provided me with
access to information necessary to make an informed choice. My signature on this document confirms my retirement plan election as
indicated in block 15 above.
THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE ANY CONTRACTUAL RIGHTS OR ENTITLEMENTS AND DOES
NOT CREATE A CONTRACT BETWEEN THE MEMBER AND THE SOUTH CAROLINA RETIREMENT SYSTEMS. THE SOUTH
CAROLINA RETIREMENT SYSTEMS RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT.
RETIREMENT PLAN ENROLLMENT
State Budget and Control Board
South Carolina Retirement Systems
Attention: Enrollment
Box 11960, Columbia, SC 29211-1960
14. Are you now receiving or have you applied to receive a monthly benefit from any of the
Retirement Systems' retirement plans?
Did you withdraw your contributions?
12. If item 11 is "Yes", indicate the name(s) of your former
employer:
13. Do you currently have a pending refund request?
2. First/ Middle Name
6. State
11. Have you ever been a
member of the South Carolina
Retirement Systems?
M=Male
F=Female
21. Original Date of Hire with Employer listed
in Items 18-19
ACTION REQUESTED (Check One):
15. Retirement Plan Election
(CHOOSE ONE)
For more information, please contact Customer Services at 803-737-6800, 800-868-9002 (within SC only), or www.retirement.sc.gov
18. Employer Code
Work Telephone Number
Employee's Signature Date Witness
DateEmployer Signature
NEW ENROLLEE (First-time membership)
OPEN ENROLLMENT (Irrevocable election from State ORP)
CHANGE OF EMPLOYER (Transfer)/DUAL EMPLOYMENT
CHANGE OF INFORMATION
Name (Prior Name):
Address
SSN (Old Number):
Date of Birth
No Yes No
Yes
No Yes No Yes
Application in Process
SCRS PORS (See Instructions)
State ORP (If State ORP, please complete item 16.)
GARS - Senator (100.01) GARS - Representative (100.02)
JSRS - Judge (001.00) JSRS - Solicitor (002.00)
VALIC MetLife TIAA-CREF
The Hartford
Primary Employer Secondary Employer
4. Address
JSRS - Circuit Public Defender (003.00)
Form 1100, Page 2 INSTRUCTIONS
09/28/2009 (PLEASE READ BEFORE COMPLETING AND SIGNING THIS FORM)
Complete this form: to enroll a new member; to change a member's employer, name, address, date of birth, or Social
Security number; for employees who have had a break-in-service (those who return from a leave-without-pay status of more
than 13 months); or when changing from one retirement system to another, regardless of prior membership.
ACTION REQUESTED - (CHECK APPROPRIATE BOX) (THE EMPLOYER MAKES THESE SELECTIONS.)
NEW ENROLLEE: Enrolling in the Retirement Systems for the first time.
OPEN ENROLLMENT: Irrevocable election from State ORP - Employee previously participated in State ORP, but is now
irrevocably electing membership in SCRS during open enrollment period, after the first annual anniversary but before the fifth
annual anniversary of the person's initial enrollment in State ORP.
CHANGE OF EMPLOYER/Dual employment: A member of the Retirement Systems transferring or accepting a position
with another employer or a new hire with funds on deposit in the Retirement Systems.
CHANGE OF INFORMATION: Changing any of the listed information and to request that the Retirement Systems update its
records on the employee accordingly.
Name (Prior Name): Attach a copy of the marriage license or other legal document authorizing the name change.
Indicate the employee's old name in the space provided and list his new name in items 1-3 in Section I.
Address: List employee's new address (items 4-7 in Section I).
SSN (Old Number): Change/correct an employee's Social Security number by listing old Social Security number in the
space provided and completing items 1-3 in Section I. (The employee's new Social Security number should be listed in
item 3 in Section I).
Date of Birth: Change an employee's date of birth by completing items 1-9 in Section I.
SECTION I - ITEMS 1-17 INSTRUCTIONS (THE EMPLOYEE COMPLETES AND SIGNS THIS SECTION.)
Items 1 - 10: Complete items 1-10 by providing the requested information.
Item 11: Indicate if you have prior membership in any of the five retirement plans (SCRS, State ORP, PORS, GARS, or
JSRS).
Item 12: If item 11 is "yes," provide the name(s) of the employer(s) for whom you worked and through which you contributed
to the Retirement Systems or State ORP, and indicate whether or not you received a refund of your contributions.
Item 13: Indicate whether or not you currently have a pending refund request.
Item 14: Indicate whether or not you are receiving or have applied to receive a monthly benefit from the Retirement Systems.
Item 15: Select the retirement plan of your choice (check appropriate box). You must be eligible for membership in the
retirement plan you select. To be eligible for PORS membership, an employee must be required by the terms of his
employment, by election or appointment, to preserve public order, protect life and property, and detect crimes in the state; to
prevent and control property destruction by fire; be a coroner in a full-time permanent position; or be a peace officer
employed by the Department of Corrections, the Department of Juvenile Justice, or the Department of Mental Health.
Probate judges and coroners may elect membership in PORS. Magistrates are required to participate in PORS for service
as a magistrate. PORS members, other than magistrates and probate judges, must also earn at least $2,000 per year and
devote at least 1,600 hours per year to this work, unless exempted by statute. By signing this form as an employer, you are
certifying that the employee meets these eligibility requirements.
Item 16: If you elected State ORP, you must check the appropriate box to indicate your vendor selection.
Item 17: Please sign and date the form after you have completed items 1-16.
Your employer will complete the remainder of the form (Section II).
SECTION II - ITEMS 18-24 INSTRUCTIONS (THE EMPLOYER COMPLETES AND SIGNS THIS SECTION.)
A COPY OF THE EMPLOYEE'S SOCIAL SECURITY CARD MUST BE ATTACHED TO THIS FORM TO ENROLL THE
MEMBER. THE NAME ON THE SOCIAL SECURITY CARD MUST MATCH THE NAME LISTED IN ITEMS 1-2 IN
SECTION I OF THIS FORM.
Items 18-19: Indicate the five-digit employer code assigned to your organization by the Retirement Systems and list the
name of your organization.
Item 20: Indicate if this will be the employee's primary or secondary employer.
Item 21: List the date the employee was originally hired by the current employer.
Item 22: List the date the employee will begin making contributions to his or her chosen retirement plan through the current
employer. If an employee is electing irrevocable membership in SCRS during the State ORP open enrollment period, the
effective date must be April 1 of the current year.
Item 23: Indicate the employee's position title.
Item 24: List the employee's annual salary. If the employee is part-time, the salary may be listed as an hourly wage.
Item 25: Please sign and date the form, and provide your work telephone number so that the Enrollment staff may contact
you if necessary.
FACULTY and STAFF EMERGENCY FORM
NAME ___________________________________
COLLEGE ID # ___________________________________
DEPARTMEN
T ________________
__________________
OFFICE LOCATION &
OFFICE NUMBER __________________________________
HOME PHON
E ___________________________________
IF SOMETHING WERE TO HAPPEN TO YOU WHILE YOU ARE AT WORK WHO SHOULD WE CALL:
EMERGENCY CONTACT NAME: ____________________________
PHONE:
_________
___________________
EMAIL ADDRESS: ___________________________
EMERGENCY CONTACT NAME: ____________________________
PHONE: ____________________________
EMAIL ADDRESS: ___________________________
E
MPLOYEE’S SIGNATURE ______________________________
DATE _______________________________
PLEASE NOTIFY THE HUMAN RESOURCES DEPARTMENT OF ANY CHANGES TO THE ABOVE INFORMATION.
Frequently Asked Questions
1. As a temporary employee (regular temporary, CWS or Adjunct Faculty)
when will I get my first paycheck?
Adjunct Instructors can expect to get paid on the last working day of each month in the following manner:
Fall Semester - 4 equal payments September – December Spring Semester – 4
equal payments February – May Summer Semester – 3 equal payments June
August
Regular Temporary Employees or College Work Study Employees will be paid in arrears on the 15
th
of the next
month. For example if you start work June 1
st
, your first check with be on July 15
th
.
2. Can I sign up for Direct Deposit for my paychecks?
All employees of York Technical College are required to sign up for direct deposit. The form is included in
the employment packet you have been given.
3. If I wanted to apply for another job on campus, can I do so and do I need to complete another application?
Any employee can apply for other positions available on campus. Jobs are posted on our website at
www.yorktech.edu/hr.
We will require you to complete a new application at that time.
4. I work at another state agency but I have no benefits is this considered dual employment?
No, if you are working at another agency in a temporary position, whether its a Temporary staff or as an
Adjunct, you are not consider to be dually employed. Only persons, holding a Full-Time Equivalent (FTE)
position at any SC State Agency (with the exception of public schools) are considered to be dually employed.
5. I work in a temporary position; will I get paid when the college is closed?
No, you can only be paid for the hours you have actually worked.
6. Where do I pick up my paycheck?
Your Pay Advice can be viewed on-line via Web Advisor. Your Web Advisor account is managed with your
College Identification Number (CID). If you have trouble accessing your account, please call our Information
Systems (IS) department at 803.981.7351.
Welcome to York Technical College! In order to receive a paycheck, you must complete all of the
information include in this packet. You must acknowledge that you are aware that if this paperwork is
not completed in a correct and timely manner you are jeopardizing your rights to be compensated for the
work that you have performed.
I understand the above statement
/
Signature Date
Name:
Home Phone #:
SS/CID #
1
st
day of work:
Department employed:
Supervisor’s name:
IMPORANT INFORMATION FOR ALL TEMPORARY EMPLOYEES
As a temporary employee you are allowed to work up to 29 hours per week. As a temporary employee
you may also choose to be in the SCRS or participate in an Optional Retirement Program or you may
choose not to participate in any plan. Please visit the PEBA webpage at: http://www.retirement.sc.gov if
you need further information.
If you do not wish to contribute to any retirement plan you must complete:
Form 1104: Election of Non-membership or If you wish to contribute to the SCRS please complete:
Form 1100 Enrollment Form (All systems)
However, if you are currently in the SCRS at another agency or if you are retired from the SCRS you
must have retirement taken from your check. You do not have a choice. You must complete one of these
two forms:
Form 1100 Enrollment Form (All systems) - Employees currently in system
Form 1114 Notification of Retired Employee Retired employees
If you decide that you would like to participate in an Optional Retirement program after viewing the
PEBA webpage, please stop by our office for more detailed information.
All SCRS forms may be found on the SCRS Website.
http://www.retirement.sc.gov/forms/numberforms.asp
Also, please note a copy of your social security card must be sent in with your enrollment forms.
Please complete this statement: I have completed FORM # for retirement purposes.
I work in more than one Department at York Technical College Yes or No
I currently work as a temporary for another State Agency Yes
or No
If yes, how many hours are you currently working per week?
I previously retired from the SCRS on this date:
Any one that retired after January 2, 2013 has an earning limitation of $10,000 per calendar year.
If you have questions, please contact.
Benefit & Wellness Manager 803.981.7183
Human Resources Assistant803.981.8009
Please send an official transcript to: Please indicate who completed this request from
the responding college/university and may be
contracted if there is a question.
Human Resources Department Name: _____________________________
York Technical College
452 S. Anderson Road Phone: _____________________________
NAME: _____________________________________________________________________
Last First Middle (Maiden)
ANOTHER NAME UNDER WHICH YOUR RECORDS MAY APPEAR
Last First Middle (Maiden)
Social Security Number _____-____-_______ Date of Birth ______/___/________
Name of School: _______________________________________________________________
Address of Schools: ___________________________________________________________
Last Date of Attendance: ______/_____/_______
Degree(s) Earned Date(s) Earned
___________________________________ ___________________________________
Name of Requestor: ____________________________________
Position(s) applied for: __________________________________
My signature below authorizes release of transcript(s).
______________________________________ ________/_____/________
Signature Date
Please forward this form to your Institution of Higher education and a form should be mailed for each degree earned.
I have been given the following policies, procedures, and/or guidelines for the
South Carolina Technical College System and York Technical College and I
realize additional information regarding these documents are in the Faculty/Staff
Handbook located in both the shared file cabinet and in the division office, on the
College’s website at www.yorktech
.edu, in the System Policy Manual on the
Technical College System intranet at www.sc.techsystem/intranet and on
www.myscgov.com/ohr in the Human Resources regulations.
Anti-Harassment Policy
York Technical College Information Security Agreement
and Guidelines
York Technical College Disclaimer Statement
Defaulting on Student Loan
Ethics Act Brochure
Statement on Alcohol and Drug Use
Tobacco Guidelines
Affordable Healthcare Act Information
By my signature, I am agreeing that I have read each of the policies, procedures,
and/or guidelines and will abide by the conditions specified.
_____________________________________ ________________________
Temporary Employee Signature Date
This statement will be placed in your personnel folder to show that you have received the policies, procedures, and/or guidelines.
Information Security Agreement
Statement of Understanding
Recognizing the need to maintain individual and institutional rights to privacy and confidentiality and realizing
that, as an agent of the College, my assigned responsibilities necessitate the handling of sensitive information
(both individual and institutional), I affirm my intention to preserve the strictest standards of confidentiality in
the use of this information and agree to be legally bound by the same regulations affecting all College officials
concerning the dissemination and disclosure of sensitive information.
Specifically, I affirm:
1. That I understand the need to exercise confidentiality in the handling of institutional information.
2. That I understand the importance of exercising care in assuring the secrecy of my computer system
passwords, the physical security of my work area, and the proper storage, transmittal, and disposal of
College based information.
3. That I have read and understand the College’s Disclosure of Education Records, Information Security
Program, and Guidelines on Use of Computing Facilities.
4. That I am ethically obliged to report any attempted or successful violation of institutional or personal
security or privacy.
5. That I have become familiar with specific information handling procedures established within my
workgroup.
6. That I understand the Computer Systems’ Administrator has access to all computer files and electronic mail
messages.
I understand the intent of this statement and will exercise diligence in performing my duties in accordance with
institutional practice. Furthermore, I understand that violation of College practice may result in disciplinary
action, up to immediate termination.
Employee/Work Study Student/Volunteer Signature _____________________________ Date__________
Print Name _____________________________________________________ Date________________
Supervisor’s Signature ____________________________________________________ Date__________
Print Name ____________________________________________________ Date________________
Disclaimer statement: THE LANGUAGE IN THIS DOCUMENT DOES NOT CREATE AN EMPLOYMENT CONTRACT BETWEEN
THE EMPLOYEE AND THE COLLEGE. THIS DOCUMENT DOES NOT CREATE ANY CONTRACTUAL RIGHTS OR
ENTITLEMENTS. THE COLLEGE RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT, IN WHOLE OR IN
PART, NO PROMISES OR ASSURANCES, WHETHER WRITTEN OR ORAL, WHICH ARE CONTRARY TO OR INCONSISTENT
WITH THE TERMS OF THIS PARAGRAPH CREATE ANY CONTRACT OF EMPLOYMENT.
Information Security Program Committee
2010
DISCLAIMER
PURSUANT TO SECTION 41-1-110 OF THE CODE OF
LAWS OF SOUTH CAROLINA, AS AMENDED, THE
LANGUAGE USED IN THE YORK TECHNICAL
COLLEGE FACULTY/STAFF HANDBOOK AND THE
SOUTH CAROLINA TECHNICAL COLLEGE SYSTEM
POLICIES AND PROCEDURE MANUAL DOES NOT
CREATE AN EMPLOYMENT CONTRACT BETWEEN
THE EMPLOYEE AND THE COLLEGE OR THE SYSTEM.
THIS HANDBOOK OR POLICIES AND PROCEDURES
MANUAL DOES NOT CREATE ANY CONTRACTUAL
RIGHTS OR ENTITLEMENTS. THE COLLEGE OR
SYSTEM RESERVES THE RIGHT TO REVISE THE
CONTENTS OF THIS HANDBOOK OR POLICIES AND
PROCEDURES MANUAL, IN WHOLE OR IN PART. NO
PROMISES OR ASSURANCES, WHETHER WRITTEN OR
ORAL, WHICH ARE CONTRARY TO OR INCONSISTENT
WITH THE TERMS OF THIS PARAGRAPH CREATE ANY
CONTRACT OF EMPLOYMENT.
I ACKOWLEDGE MY RECEIPT AND UNDERSTANDING
OF THIS DISCLAIMER. I FURTHER ACKNOWLEDGE
THAT ALL PREVIOUSLY ISSUED HANDBOOKS OR
POLICIES AND PROCEDURES MANUALS ARE
WITHDRAWN AND ARE OF NO FURTHER FORCE OR
LEGAL EFFECT.
NAME DATE
South Carolina Law Prohibits
EMPLOYMENT DISCRIMINATION
Examples of conduct covered under the law:
Failure to Hire or Promote
Unequal Wages
Harassment/Intimidation
Discipline/Demotion/Suspension/Termination
Applying Different Terms and Conditions of Employment
Failure to Reasonably Accommodate due to a disability,
religion, pregnancy, childbirth or related medical
conditions, including, but not limited, to lactation
Retaliation as a result of complaining about
discrimination, seeking an accommodation, or
participating in a discrimination investigation
How to report unlawful discrimination:
Complete a questionnaire via phone, in-person, mail, or online
at www.schac.sc.gov. Once submitted, a SCHAC Intake Officer
will contact you and assist you in filing a formal complaint.
You must file a formal complaint to launch an investigation.
There are strict time limits for filing charges of employment
discrimination. To preserve the ability to act on your behalf
and to protect your right to file a private lawsuit, should you
ultimately need to, you should contact SCHAC promptly when
discrimination is suspected.
EQUAL EMPLOYMENT OPPORTUNITY IS THE LAW
South Carolina Human Affairs
Commission
1026 Sumter Street, Suite 101
Columbia, SC, 29201
www.schac.sc.gov
Phone: 803-737-7800
Toll- Free: 1-800-521-0725
Employers, including each State Agency, or department of the State, and local subdivision thereof, SHALL POST, KEEP POSTED, AND MAINTAINED IN
CONSPICUOUS PLACES UPON THEIR PREMISES
where notices to employees and applicants for employment are customarily posted a notice to be prepared and
distributed by the Commission setting forth excerpts from and/or summaries of, pertinent provisions of the Human Affairs Law, and information pertinent to the filing of
a complaint.
Based on: Race, Color, Religion, National Origin, Sex, including Pregnancy & Childbirth (or
related medical conditions), Age (over 40), or Disability
In Addition to Employment, the
Mission of SCHAC is to eliminate and
prevent unlawful discrimination in:
Housing on the basis of race, color,
national origin, religion, sex, familial
status or disability.
Public Accommodations on the basis
of race, color, national origin or
religion.
Persons Defaulting on Certain Student Loans are Precluded
from Employment by the State of South Carolina
No person who has willfully defaulted on a National Direct
Student Loan, a National Defense Student Loan, a Nursing
Student Loan, a Health Professional Student Loan or a Law
Enforcement Educational Loan shall now or hereafter be employed
by the State or any of its departments, agencies or subdivision until
all defaults are cured and loan payments made current; provided
however, that if such person and his lender voluntarily enter into
an agreement after default under which terms enter the debt will be
repaid and the lender confirms this agreement in writing with the
state agency, department of subdivision, the loan shall not be
considered in default and the default shall be considered as cured
so long as the person complies with the terms of the agreement.
Act #375 of the 1980 S.C. General Assembly, effective April 23, 1980
SOUTH CAROLINA TECHNICAL COLLEGE SYSTEM
STATEMENT ON ALCOHOL AND DRUG USE
It is the policy of the South Carolina Technical College System to provide a drug free, healthful, safe and secure
work environment. Employees are required and expected to report to work in appropriate mental and physical
condition to meet the requirements and expectations of their positions.
The South Carolina Technical College System prohibits the unlawful manufacture, distribution, dispensation,
possession of and use of narcotics, drugs, other controlled substances or alcohol at the workplace. Workplace
means either on agency premises or while conducting agency business away from the agency premises.
The South Carolina Technical College System recognizes that chemical dependency through use of controlled or
uncontrolled substances, including alcohol, is a treatable illness. The agency supports and recommends
employee rehabilitation and assistance programs and encourages employees to use such programs.
York Technical College will also implement drug-free awareness programs. Such programs will ensure that
employees are aware that:
1. Drug and alcohol abuse at the workplace is dangerous because it leads to physical impairment, loss of
judgment, safety violations and the risk of injury or even death.
2. Drug and alcohol abuse can significantly lower performance on the job thus impacting on the agency
and college mission.
3. In order to prevent the consequences of drug and alcohol abuse at the workplace the South Carolina
Technical College System has implemented this policy to ensure that the workplace is drug-free.
4. Employees must report to their personnel officer within five days any convictions, under a criminal
drug statute, for conduct at the workplace.
5. It is a condition of employment that all employees must abide by the policy on employee alcohol/drug
use and accompanying statements. Violation of any provisions herein may result in disciplinary action
up to and including termination and may have further legal consequences. Additionally, management
may require an employee to enter an employee assistance or drug rehabilitation program.
6. Full-time employees may use our employee assistance program (EAP) which is available 24 hours a day
by contacting:
First Sun
Employee Assistance Program
Rock Hill, SC 29732
(Toll-Free) 1-800-968-8143
www.firstsuneap.com
Anti-Harassment Policy
(State Board for Technical and Comprehensive Education Policy 8-5-101)
York Technical College is committed to maintaining an academic and work
environment that is free of discrimination and promotes the mutual respect of all
students and employees of the College. In keeping with this commitment, the
College will not tolerate harassment of its employees by anyone, including any
supervisor, co-worker, vendor, client or its students. Harassment consists of
unwelcome conduct, whether verbal, physical or visual, that is based upon a
person’s protected status, such as sex, color, race, religion, national origin, age,
disability, or other protected status. Harassing conduct that affects tangible job
benefits, interferes unreasonably with an individual’s work performance or
creates an intimidating, hostile, or offensive working environment will not be
tolerated. Sexual harassment is the typical form of harassing behavior and
deserves special mention. Unwelcome sexual advances, requests for sexual
favors, and other physical, verbal, or visual conduct based on sex constitutes
sexual harassment when: (1) submission to the conduct is an explicit or implicit
term of condition of employment, (2) submission to or rejection of the conduct is
used as the basis for an employment decision, or (3) the conduct has the purpose
or effect of unreasonably interfering with an individual’s work performance or
creating an intimidating, hostile, or offensive working environment. Sexual
harassment may include explicit sexual propositions, sexual innuendo,
suggestive comments, sexually oriented “kidding” or “teasing,” “practical jokes,”
jokes about gender-specific traits, foul or obscene language or gestures, displays
of foul or obscene printed or visual material, and physical contact such as
patting, pinching, rubbing or intentionally brushing against another’s body. All
employees are responsible for helping to eliminate all forms of harassment in the
workplace. If any employee feels that he or she has experienced or witnessed
harassment, the immediate supervisor, the Human Resources Director, or the
appropriate Vice President should be promptly notified. The College strictly
prohibits retaliation against anyone that has reported harassment in good faith or
otherwise participated in an investigation of harassment. Harassment complaints
will be investigated as promptly and thoroughly as possible. The Human
Resources Director will normally conduct the investigation; however, in certain
situations, another impartial investigator may be designated. If the investigation
reveals that the complaint is valid and that harassment has occurred, the College
will take immediate appropriate action to stop the harassment and prevent it from
continuing in the future. Investigations will remain confidential to the maximum
extent possible.
Page | 1
DISCLAIMER
PURSUANT TO SECTION 41-1-110 OF THE CODE OF LAWS OF SC, AS AMENDED, THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE AN
EMPLOYMENT CONTRACT BETWEEN THE EMPLOYEE AND THE AGENCY.
Rev. 06/08
South Carolina State Ethics Commission
Rules of Conduct
General Information
All public employees, public officeholders, and public members are expected to adhere to and follow the
Rules of Conduct as outlined in the Ethics Reform Act. Anyone who is found guilty of violating these
rules is subject to prosecution by the State Ethics Commission and the Attorney General's Office.
A public official, public member, or public employee may not knowingly use his official office,
membership, or employment to influence a government decision to obtain an economic interest for
himself, a member of his immediate family, an individual with whom he is associated, or a business with
which he is associated.
A person may not directly or indirectly give, offer, or promise anything of value to a public official,
public member, or public employee with intent to influence the public official's, public member's, or
public employee's official responsibilities, nor is the public official, public member, or public employee
to ask, demand, solicit, or accept anything of value for himself or for another person in return for
fulfilling his official responsibilities or duties.
A public official, public member or public employee may not receive anything of value for speaking
before a public or private group in his/her official capacity. A meal can be accepted if provided in
conjunction with the speaking engagement where all participants are entitled to the same meal and the
meal is incidental to the speaking engagement. A public official, public member or public employee may
receive payment or reimbursement for actual expenses incurred.
Public officials, public members, or public employees may not receive money in addition to that received
by the public official, public member, or public employee in his official capacity for advice or assistance
given in the course of his employment as a public official, public member, or public employee.
No public official, public member, or public employee may disclose confidential information gained as a
result of his responsibility as a public official, public member, or public employee that would affect an
economic interest held by himself, a member of his immediate family, an individual with whom he is
associated, or a business with which he is associated.
No person may serve as a member of a governmental regulatory agency that regulates any business with
which that person is associated.
No person shall serve on the governing body of a state; county; municipal; or political subdivision,
board, or commission and serve in a position of the same governing body which makes decisions
affecting his economic interests.
A public official occupying a statewide office, a member of his immediate family, an individual with
whom he is associated, or a business with which he is associated may not knowingly represent another
person before a governmental entity.
Page | 2
DISCLAIMER
PURSUANT TO SECTION 41-1-110 OF THE CODE OF LAWS OF SC, AS AMENDED, THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE AN
EMPLOYMENT CONTRACT BETWEEN THE EMPLOYEE AND THE AGENCY.
Rev. 06/08
No member of the General Assembly or an individual with whom he is associated or business with
which he is associated may represent a client for a fee in a contested case before an agency, a
commission, board, department, or other entity if the member of the General Assembly has voted in the
election, appointment, recommendation, or confirmation of a member of the governing body of the
agency, board, department, or other entity within the 12 preceding months.
A public member occupying statewide office, an individual with whom associated, or a business with
which associated may not knowingly represent a person before the same unit or division of the
governmental entity for which the public member has official responsibility.
A public official, public member, or public employee of a county or municipality, an individual with
whom associated, or a business with which associated may not knowingly represent a person before any
agency, unit, or subunit of that county or municipality.
A public employee, other than of a county or municipality, an individual with whom associated, or a
business with which associated may not knowingly represent a person before an entity of the same level
of government for which the public employee has official responsibility.
No public official, public member or public employee may cause the employment, appointment,
promotion, transfer, or advancement of a family member to a state or local office or position in which the
public official, public member or public employee supervises or manages. A public official, public
member, or public employee may not participate in an action relating to the discipline of the public
official's, public member's or public employee's family member.
A former public official, former public member, or former public employee holding office, membership,
or employment may not serve as a lobbyist or represent clients before the agency or department on
which the public official, public member, or public employee formerly served in a matter in which he
directly and substantially participated for one year after terminating his public service or employment.
It is a breach of ethical standards for a public official, public member, or public employee who
participates directly in procurement to resign and accept employment with a person contracting with the
governmental body if the contract falls or would fall under the public official's, public member's, or
public employee's official responsibility.
No person may use government personnel, equipment, materials, or an office building in an election
campaign. A person may use public facilities for a campaign purposes if they are available on similar
terms to all candidates and committees. Likewise, government personnel may participate in election
campaign on their own time and on non-government premises.
A public official, public member, or public employee may not have an economic interest in a contract
with the state or its political subdivisions if the public official, public member, or public employee is
authorized to perform an official function (including writing or preparing the contract, accepting bids,
and awarding of the contracts) relating to the contract.
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Tobacco Guidelines
The use of tobacco products is permitted only within personal vehicles. York Technical
College prohibits the use of all tobacco products in any form elsewhere on campus and in
College vehicles.
York Technical College has a responsibility to provide a safe and healthful environment. In
response to feedback from students, faculty, and staff, the College will be implementing a change
in the tobacco-use guidelines.
New Guideline: Effective September 1, 2010, York Technical College prohibits the use of all
tobacco products, in any form, except in personal vehicles.
Clarification of Prohibited Areas: Specifically, tobacco use is prohibited in all campus buildings,
including classrooms, laboratories, shops, offices, work areas, study areas, reception areas,
meeting rooms, lobbies, hallways, stairwells, elevators, eating areas, lounges, restrooms and in
all partially enclosed areas such as covered walkways. Additionally, smoking is prohibited on
campus grounds (except in personal vehicles), at all off-campus centers, at off-campus college-
sponsored activities and in all York Technical College vehicles.
Definition of Tobacco Products: Tobacco products include, but are not limited to, cigarettes,
cigars, pipes, and smokeless tobacco.
Disposal: Ashtrays and smoking shelters will not be provided on campus grounds. Prospects,
students, and employees are expected to dispose of the residue from their tobacco products safely
and appropriately in their vehicles.
Monitoring: Public Safety will advise individuals who are not in compliance with the College's
tobacco-use guidelines to dispose of their tobacco products appropriately. Any observed student
violations of the tobacco-use guidelines should be reported immediately to the Public Safety
Office (803) 327-8013. Any observed employee violations should be reported to the employee's
direct supervisor.
Warnings: Visitors on campus will be issued warning citations if they violate the tobacco-use
guidelines. Students and employees, initially, will also be issued warning citations for first
offenses; however, fines will be assessed for repeat offenses.
Violations: South Carolina's Clean Indoor Air Act of 1990 cites violation of the act as a
misdemeanor which, upon conviction, results in a fine. Tobacco use in prohibited areas is also
punishable by fines and/or disciplinary action.
Fines: The issuance of a fine is at the discretion of the Public Safety Office. Students who violate
the tobacco-use guidelines will be given a warning citation for their first offense. Subsequent
violations will result in the student being fined $25 for each subsequent offense. College
employees who violate the tobacco-use guidelines will be given a warning for their first offense.
Subsequent violations will result in the employee being fined $25 for each subsequent offense.
Disciplinary Action: Students who habitually violate the tobacco-use guidelines will be referred
to the Dean for Students Office for possible disciplinary action. Employees who habitually
violate the tobacco-use guidelines will be referred to their supervisors for progressive
disciplinary action.
Cooperation: Effective implementation of these guidelines depends upon the courtesy, respect,
and cooperation of all members of the York Technical College community.
Educational Programs: York Technical College will provide programs to help students and
employees stop using tobacco products. These tobacco treatment programs will be publicized on
the College's website and in student and employee communications.
Comments: If you have questions, comments, or concerns regarding this information, please
contact Kelli Dawkins, Dean for Students, at kdawkins@yorktech.edu. You can also discuss the
tobacco guidelines on York Tech's Facebook page.
For more information as well as free programs and resources to help you stop using
tobacco, visit http://www.scdhec.gov/health/chcdp/tobacco/quitforkeeps.htm.
New Health Insurance Marketplace Coverage
Options and Your Health Coverage
Form Approved
OMB No.
PART A: General Information
When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance
:
the Health
Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic
information about the new Marketplace and employment based health coverage offered by your employer.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The
Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible
for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance
coverage
through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or
offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on
your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible
for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be
eligible for a tax credit that lowers your monthly premium or a reduction in certain cost-sharing if your employer does
not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your
employer that would cover you (and not any other members of your family) is more than 9.5% of your household
income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the
Affordable Care Act, you may be eligible for a tax credit.
1
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your
employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer
contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for
Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-
tax basis.
How Can I Get More Information?
For more information about your coverage offered by your employer, please check your summary plan description or
contact: York Technical College, Human Resources Department, Benefits Department, 803-327-8009.
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the
Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health
insurance coverage and contact information for a Health Insurance Marketplace in your area.
1
An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered
by the plan is no less than 60 percent of such costs.
PART B: Information About Health Coverage Offered by Your Employer
This section contains information about any health coverage offered by your employer. If you decide to complete an
application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered
to correspond to the Marketplace application.
3. Employer name
York Technical College
4. Employer Identification Number (EIN)
576024198
5. Employer address
452 S. Anderson Road
6. Employer phone number
803-327-8009 or 803-981-7183
7. City
Rock Hill
8. State
SC
9. ZIP code
29730
10.
Who can we contact about employee health coverage at this job?
Human Resources Benefits Department
11. Phone number (if different from above)
803-327-8009 or 803-981-7183
12. Email address
yorktech.edu/hr
Here is some basic information about health coverage offered by this employer
:
As your employer, we offer a health plan
to:
1.
All
employees
2.
Some employees. Eligible employees are: Employees that are in a full-time position
for calendar year 2014. In 2015 an employee that works 30 or more hours a week.
With respect to dependents:
1.
We do offer coverage.
2.
Eligible dependents are: If employee is eligible for insurance then their spouse and children under the
age of 26 are also eligible.
We do not offer coverage.
If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended
to
be affordable, based on employee wages.
** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium
discount
through the Marketplace. The Marketplace will use your household income, along with other factors,
to
determine whether you may be eligible for a premium discount. If, for example, your wages vary from
week to
week (perhaps you are an hourly employee or you work on a commission basis), if you are newly
employed
mid-year, or if you
have other income losses, you may still qualify for a premium discount.
If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's
the
employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower
your
monthly premiums.
The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for
employers, but will help ensure employees understand their coverage choices.
Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in
the
next 3 months?
Yes
(Continue)
13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the
employee eligible for coverage? (mm/dd/yyyy) (Continue)
No
(STOP and return this form to employee)
An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by
the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
Business Casual Dress Guidelines
York Technical College strives to project a professional image for our students, potential employees, and community
visitors. Business casual dress is the standard for appropriate dress for College employees. This is a general
overview of appropriate business casual attire and not intended to be all inclusive. This information provides generally
acceptable business casual attire and what is generally not acceptable as business casual attire. Actual attire should
be based on an employee’s specific job duties and work environment. No dress code can cover all contingencies so
employees must exert a certain amount of judgment and discretion in their choice of clothing to wear to work.
Supervisors/managers should also exercise appropriate judgment and discretion when it is determined that an
employee is inappropriately dressed. If you experience uncertainty about acceptable, professional business casual
attire for work, please contact a representative from the Human Resources Office.
Slacks, Pants, and Suit Pants
Slacks that are similar to Dockers and other makers of cotton or synthetic material pants, wool pants, flannel pants, and
nice looking dress synthetic pants are acceptable.
Examples of Inappropriate dress: jeans, sweatpants, exercise pants, pants worn below waist, Bermuda shorts, short
shorts, shorts, capris, leggings, and any spandex or other form-fitting pants .
(Please note that jeans may be acceptable within certain departments/shop areas within the College).
Skirts, Dresses, and Skirted Suits
Casual dresses and skirts, and skirts that are split at or below the knee are acceptable. Dress and skirt length should be
at a length at which you can sit comfortably in public.
Examples of Inappropriate dress: Mini-skirts. Tube, beach dresses, and spaghetti-strap dresses.
Shirts, Tops, Blouses, and Jackets
Casual shirts, dress shirts, sweaters, tops, golf-type shirts, and turtlenecks. Most suit jackets or sport jackets are also
acceptable attire for the office.
Examples of Inappropriate dress: Tank tops; midriff tops; shirts with potentially offensive words, terms, logos,
pictures, cartoons, or slogans; halter-tops; tops with bare shoulders; sweatshirts, and t-shirts unless worn under
another blouse, shirt, jacket, or dress.
Shoes and Footwear
Conservative athletic or walking shoes, loafers, clogs, sneakers (as appropriate), boots, flats, dress heels, and leather
deck-type shoes.
Examples of Inappropriate dress: Flip-flops, and slippers. Closed toe and closed heel shoes may be required in certain
departments within the College for safety reasons.
Body Jewelry and Tattoo’s
Limited visible body piercing is suggested unless it is an expression or requirement for religious purposes. Tattoo’s
should not be visible, particularly those that are large in size and could be perceived as offensive by others.
Perfume and Cologne
Wear these substances with restraint. Remember, some employees and students are allergic to the chemicals in
perfumes and colognes.
Hair, Hats, and Head Covering
Hair should be neatly styled and should be of natural human hair colors. Hats are not appropriate in the office unless for
safety or health reasons. Head coverings that are required for religious purposes or to honor cultural tradition are
allowed/permitted.
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