COVER SHEET FOR RECOMMENDED SPEAKER/CONSULTANT
Process to follow for approval:r Speaker/Consultant completes application
r Recommending Administrator signs and attaches cover sheet with Account Number(s)—and signature of Fund Manager if required (make a copy for your records, if needed)
r Recommending Administrator or Fund Manager submits cover sheet, application to Tina Moore-Human Resources
r Human Resources conducts SLED/SCSO check and returns packet to Recommending Administrator
Assistant Superintendent of Human Resources Status
Date
r Human Resources forwards completed application packet to Payroll and notifies Recommending Administrator
r Recommending Administrator submits completed Administrative Payroll Non-Contract Timesheet to Payroll for payment when contract is fulfilled (form is also available on the DCSD web site, www.darlington.k12.sc.us)
Name of Speaker/Consultant:
Name must appear exactly as listed on social security card
Address:
Telephone No. ( ) Email Address
Recommending Administrator:
ü Please insure that all required application documents are attached
ü Complete the following payment information
Required Forms (additional information needed to process payment):
1. Attach copy of driver license and social security card
2. Completed and signed W-4 Form
3. Form I-9 and documents to accompany it (if not using driver license and social security card in #1)
4. Signed 403(b) Notification Form
5. Signed SC Retirement System Optional Membership Form
6. One of the following to indicate how retirement funds should be addressed
a. Form 1100 and Form 1102 or
b. Form 1104 or
c. Form 1114 * (required for all SC Retirement/TERI participants)
* Form 1114 is required for all SC Retirement System and TERI participants)
- Speaker/Consultant: Please retain a copy of the above-listed items, as needed, for your records -
Payment Information
(for District use only)
Signature of Recommending Administrator Date
Signature of Fund Manager, if required Date
SLED Background check will be billed to account # - - - - -
This Speaker/Consultant will be paid on an hourly basis (timesheet required):
$
Number of Hours Rate Per Hour
This Speaker/Consultant will be paid a stipend in the amount of $
Account Number(s): - - -
Account Number(s): - - -
Application
Speakers/Consultants for Darlington County School District
A person is not approved to work in the schools of the Darlington County School District (DCSD)
until the SLED check has been completed.
Name: Telephone No:
Name must appear exactly as listed on social security card
Address:
Street City State Zip Code
Social Security Number / /
Are you a TERI participant? Yes No If yes, on what date did you begin the TERI program?
mm/dd/yyyy
Required Information for Payroll and Human Resources:
1. Copy of Valid SC Driver License
2. Recent SLED/SCSO Check Conducted by Department of Human Resources
For statistical purposes and state law enforcement (SLED) background check: Date of Birth
- Please attach a copy of your Social Security card, driver license (or photo identification) -
RELEASE FOR BACKGROUND CHECK: I herewith authorize Darlington County School District to request and receive confidential release of documentary materials relating to me, regardless of physical form or characteristics, prepared, owned, used, in the possession of, or retained by city, county, state, and federal law enforcement authorities.
Signature: Date:
DCSD Supervisor:
Please forward completed application, copy of driver license, and copy of social security card
to Tina Moore, Department of Human Resources.
After the SLED check has been conducted by Human Resources, the Recommending Administrator will be notified.
Through the Family Independence Act of 1995, state agencies are actively recruiting welfare and food stamp recipients. Are you currently receiving AFC benefits or food stamps? (A yes answer will not disqualify you from employment with the Darlington County School District. We must ask this question pursuant to South Carolina Law solely for reporting purposes.) Yes No
An Equal Opportunity Employer
The Darlington County School District will provide equal employment opportunities to otherwise qualified individuals without regard to race, color, religion, gender, age, disability, national origin, or genetic information.
01/15/2015
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