Office of Human Resources, P.O. Box 5000, Annandale‐on‐Hudson, NY 12504‐5000 Tel: 845‐758‐7428 Fax: 845‐758‐7826 Email: [email protected] Please print clearly, Answer all sections. These forms must be completed as part of the new hire process. Position Name Address Age (only if under 18 and a student) Social Security Number 1. Have you ever been employed by or applied for a position with Bard College, under either the same or a different name? If yes, please give application date or employment dates and position held. 2. Are you a citizen of the United States or an alien authorized to work in the U.S.? 3. Have you ever been convicted of any crime (other than motor vehicle violations)? If yes, please describe the nature of the crime & the outcome of the case. Note that conviction of crime is not necessarily a bar to employment. Have you ever been convicted of a felony, or a misdemeanor involving any violent act, use or possession of a weapon or act of dishonesty for which the record has not been sealed or expunged? If so, please explain. Note that conviction of a crime is not necessarily a bar to employment. Complete sections 4, 5, and 6 only if the position for which you are applying requires driving. 4. Driver’s license number 5. Driver’s license classification 6. Have you been convicted of a motor vehicle violation within the past 3 years? If yes, please specify. Have you been driving for at least 3 years? If no, for how long have you been driving? I attest that all information herein is true and complete to the best of my knowledge. AGREEMENT I authorize a College representative to contact references, employers, schools, or other individuals to conduct a professional investigation and inquiry concerning matters related to employment as may be necessary to arrive at a hiring decision. I hereby release employers, schools, and other individuals from all liability in responding to inquiries in connection to my application. I understand that the contents of this application are provided to express my interest in securing employment with Bard College and that this application does not serve to create an employment contract between Bard College and an applicant or employee, either for employment or regarding any particular term or condition of employment. In the event of employment, I understand that giving false or misleading information on my application or during an interview may result in discharge. I further understand that accepting employment with Bard College means I agree to accept and adhere to all policies and procedures of the College. Any offer of employment is subject to compliance under the Immigration and Control Act of 1986. The appropriate verification of identity and right to work in the U.S. and completion of the I‐9 Employment Eligibility Certification are required documentation. This documentation must be provided with 72 hours after the applicant has been hired; if it is not, the offer of employment is void. I do do not give my permission to Bard College to use the information I have supplied in the Applicant Date Signature of applicant Date APPLICANT DATA RECORD The submission of this information is voluntary. The information is used for equal employment opportunity and affirmative action reporting only. Applicants are considered for all positions and employees are rated during employment without regard to race, color, religion, sec, sexual orientation, national origin, age, or handicapping conditions. As an employer, Bard College complies with government regulations and affirmative action responsibilities in record keeping and reporting. This information will be kept in a confidential file, separate from the application for employment, and will not be used in the hiring process. Referral Sources (check one): Advertisement Friend Relative Current Staff Other (specify) Sex: Male Female Racial/Ethnicity Self Identification: Are you Hispanic or Latino? Yes No Select one or more of the following races: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Island White Revised 3/1/2021 Employment Eligibility Verification USCIS Department of Homeland Security Form I-9 OMB No. 1615-0047 U.S. Citizenship and Immigration Services Expires 10/31/2022 ► 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 (Alien Registration Number/USCIS Number): 4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): Some aliens may write "N/A" in the expiration date field. (See instructions) QR Code - Section 1 Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: Do Not Write In This Space An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number. 1. Alien Registration Number/USCIS Number: OR 2. Form I-94 Admission Number: OR 3. Foreign Passport Number: Country of Issuance: Signature of Employee Today's Date (mm/dd/yyyy) Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1. (Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.) I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct. Signature of Preparer or Translator Today's Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Address (Street Number and Name) City or Town State ZIP Code Employer Completes Next Page Form I-9 10/21/2019 Page 1 of 3 LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED Employees may present one selection from List A or a combination of one selection from List B and one selection from List C. LISTA LIST B LISTC Documents that Establish Documents that Establish Documents that Establish Both Identity and Identity Employment Authorization Employment Authorization OR AND 1. U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number State or outlying possession of the card, unless the card includes one of 2. Permanent Resident Card or Alien United States provided it contains a the following restrictions: Registration Receipt Card (Form 1-551) photograph or information such as (1) NOT VALID FOR EMPLOYMENT name, date of birth, gender, height, eye 3. Foreign passport that contains a color, and address (2) VALID FOR WORK ONLY WITH temporary 1-551 stamp or temporary INS AUTHORIZATION 1-551 printed notation on a machine- 2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH readable immigrant visa government agencies or entities, OHS AUTHORIZATION provided it contains a photograph or 4. Employment Authorization Document information such as name, date of birth, 2. Certification of Birth Abroad issued that contains a photograph (Form gender, height, eye color, and address by the Department of State (Form 1-766) FS-545) School ID card with a photograph 3. Certification of Report of Birth 5. For a nonimmigrant alien authorized 3. to work for a specific employer 4. Voter's registration card issued by the Department of State because of his or her status: (Farm DS-1350) 5. U.S. Military card or draft record a. Foreign passport; and 4. Original or certified copy of birth certificate issued by a State, b. Form 1-94 or Form l-94A that has 6. Military dependent's ID card the following: county, municipal authority, or 7. U.S. Coast Guard Merchant Mariner territory of the United States (1) The same name as the passport; Card bearing an official seal and Native American tribal document (2) An endorsement of the alien's 8. 5. Native American tribal document nonimmigrant status as long as 9. Driver's license issued by a Canadian 6. U.S. Citizen ID Card (Form 1-197) that period of endorsement has government authority not yet expired and the 7. Identification Card for Use of proposed employment is not in For persons under age 18 who are Resident Citizen in the United conflict with any restrictions or unable to present a document States (Form 1-179) limitations identified on the form.