AUTHORIZATION TO WORK
Welcome to Northland Pioneer College! We are excited to have you as part of our
team. To ensure proper and prompt payment of salary, the attached forms need to be completed.
Check off each item as it is verified. Please read instructions on all forms before filling them
out. All forms must be error free and completed in full.
[
]
1. I-9 EMPLOYMENT ELIGIBILITY VERIFICATION: (Take this form with the
needed documentation to your closest NPC Campus or Center for verification.) NOTE:
See back of I-9 form for list of documents.
[
] 2. PERSONAL DATA SEGMENT: To be completed and signed by employee.
[
]
3. W-4 FEDERAL WITHHOLDING: To be completed and signed by employee per
federal law.
[
]
4. A-4 STATE WITHHOLDING: To be completed and signed by employee.
[
]
5. STATEMENT OF REGISTRATION STATUS: Every person (male or female) must
complete this form and sign it.
[
]
6. ARIZONA STATE RETIREMENT STATUS FORM: To be completed and signed by
employee.
[
]
7. DIRECT DEPOSIT FORM
You will not be allowed to work until you have been approved with a “good to go” from
Human Resources. You will not receive a payroll check until we have received these
completed forms from you.
If you have any questions or need assistance please call Human Resources at 928-524-7473.
Thank you for your cooperation.
PCN # ____________________
CARS # __________________
(For Payroll Use Only)
(For HR Use Only)
PERSONAL DATA SEGMENT
CLASSIFICATION
Full-time
Part-time
Adjunct Faculty
Student Work Study
Temporary
Tutor
Other ________________________
New Employee
Information Update
PURPOSE
Name Change* (Previous Name ___________________________)
*Required employment forms must be completed to change name.
NAME: ___________________________________________ SOCIAL SECURITY #: ______________________
STREET ADDRESS: ___________________________________________________________________________
CITY: _____________________________________ STATE: ___________________ ZIP: ___________________
MAILING ADDRESS: __________________________________________________________________________
(If different from street address)
TELEPHONE: _____________________________________ EMAIL: ___________________________________
BIRTHDATE: ______________________________________
GENDER:
Male
Female
CURRENT RETIREMENT STATUS
AZ State Retirement Member
AZ State Retirement Retiree (Retirement Date: ________)
Neither
EMERGENCY CONTACT
NAME: _______________________________________________________________________________
RELATIONSHIP: ______________________________________________________________________
ADDRESS: ____________________________________________________________________________
TELEPHONE: _________________________________________________________________________
I certify that the above information is true and correct.
________________________________________________
Signature
_______________________
Date
Northland Pioneer College does not discriminate on the basis of race, color, national origin, religion, marital status, gender, age or disability in admission or access to, or treatment or employment in its
educational programs or activities. District grievance procedures will be followed for compliance with Title IX and Section 504 requirements. The Affirmative Action Compliance Officer is the Director of Human
Resources, 2251 E. Navajo Blvd., Holbrook, Arizona 86025, (800) 266-7845. The Section 504 Compliance Officer is the Coordinator of Disability Resources and Access, 1001 W. Deuce of Clubs, Show Low,
Arizona 85901, (800) 266-7845. The lack of English language skills will not be a barrier to admission and participation in vocational education programs. Revised 2-26-10
(Rev. 5/2010)
DIRECT DEPOSIT
EMPLOYEE AUTHORIZATION FOR AUTOMATIC DEPOSITS
Not-Negotiable
NORTHLAND PIONEER COLLEGE
P. O. Box 610
Holbrook, AZ 86025
I hear by authorize__________________________________________________________________ to initiate
credit entries, and if necessary debit entries, and adjustments for any credit entries in error in my (our)
checking account (indicated below), and the depository named below to credit and/or debit the same to such
account.
FINANCIAL INSTITUTION NAME _______________________________________________________
ADDRESS ____________________________________________________________________________
CITY _______________________________________________________STATE __________________
BANK BRANCH LOCATION______________________________________________
ACCOUNT NUMBER_____________________________________________________
This authority is to remain in full force and effect until you have received written notification from me of its
termination.
NAME________________________________________________________NPC ID__________________
DATE_________________SIGNATURE_______________________________________
SIGNATURE_______________________________________
CHECKING
OR
SAVINGS
Routing and transit number
___________________________
Account Number Identification
_____________________________
Staple Voided Check Here
NORTHLAND PIONEER COLLEGE PAYROLL DEPT Listed below are deduction codes as shown on your pay stub. These codes will help you determine what is being taken out of your payroll check. For questions concerning the deductions or codes please call the payroll office. Required Deductions CODE ASRS RETR FITM FITS FITX INSR LIFE LTDE LTDR MEDI MEDR OASI OASI SITA SITB SITC SITD SITE SITF SITG DESCRIPTION AZ State Retirement – Employee Contribution AZ State Retirement – Employer Contribution Federal Income Tax – Married Federal Income Tax – Single Exempt – no deductions taken out Employer paid Medical/Dental Insurance Employer-­‐Paid Life Insurance Tax Cost over $50,000 Long Term Disability – Employee Contribution Long Term Disability – Employer Contribution Medicare – Employee Contribution ( Medicare – Employer Contribution ( FICA Employee Contribution FICA Employer Contribution State Income Tax at 0% of Gross taxable wages State Income Tax at 1.3% of Gross taxable wages State Income Tax at 1.8% of Gross taxable wages State Income Tax at 2.7% of Gross taxable wages State Income Tax at 3.6% of Gross taxable wages State Income Tax at 4.2% of Gross taxable wages State Income Tax at 5.1% of Gross taxable wages Voluntary Deductions CODE ASRA-­ASRC AFL AFLC CARE CASO CLHS FLEX GARF GARN INRP PPL TIAA TVAL VISR DESCRIPTION Arizona State Retirement Buyback AFLAC Pre-­‐tax Insurance AFLAC Insurance NPC Care Fund Donations Classified Donations Clearinghouse for child/spousal support Flex Spending Account Garnishment fee Garnishment Medical Insurance Pre Paid Legal Service Tiaa/Cref Pre Tax Annuity VALIC AVESIS pre tax eye insurance Employee’s Arizona Withholding
Percentage Election
ARIZONA FORM
A-4
2010
NOTE: This form is effective for wages paid after June 30, 2010.
Type or print your full name
Your social security number
Home address (number and street or rural route)
City or town, state, and ZIP code
Arizona Withholding Percentage Election Options
Choose only one:
1
…
My annual compensation is $15,000 or more. I choose to have Arizona withholding at the rate of
(check only one box): … 1.8%
… 2.7%
… 3.6%
… 4.2%
… 5.1% of my gross taxable wages.
Additional amount to be withheld per paycheck $
2
…
My annual compensation is less than $15,000. I choose to have Arizona withholding at the rate of
(check only one box): … 1.3%
… 1.8%
… 2.7%
… 3.6%
… 4.2%
… 5.1% of my gross taxable wages.
Additional amount to be withheld per paycheck $
3
…
•
•
I hereby elect an Arizona withholding percentage of zero, and I certify that I meet BOTH of the following qualifying conditions for this election:
I had NO Arizona tax liability for the prior taxable year, AND
I expect to have NO Arizona tax liability for the current taxable year.
I certify that I have made the percentage election marked above.
SIGNATURE
DATE
EMPLOYEE’S INSTRUCTIONS
Arizona Revised Statutes (ARS) §43-401 requires your employer to withhold
Arizona income tax from your compensation paid for services performed
in Arizona for application toward your Arizona income tax liability. Arizona
withholding is a percentage of your gross taxable wages of every paycheck.
“Gross taxable wages” is the amount from each paycheck that will be included
in box 1 of your federal Form W-2 at the end of the calendar year (i.e. gross
wages net of pretax deductions, such as your portion of health insurance
premiums). You may also have your employer withhold an additional amount
from each paycheck.
Complete this form to elect an Arizona withholding percentage and any
additional amount to be withheld from each paycheck. Give the completed
form to your employer.
Current Employees
ALL EMPLOYEES ARE REQUIRED TO COMPLETE THIS FORM FOR
WAGES PAID AFTER JUNE 30, 2010. Complete this form to elect an Arizona
withholding percentage and designate an additional amount to be withheld.
If you want to increase or decrease the amount of Arizona withholding in the
future, you must complete this form again to change the Arizona withholding
percentage or change the additional amount withheld.
New Employees
Complete this form within the first five days of employment to elect an Arizona
withholding percentage. You may also have your employer withhold an
ADOR 91-0041 (6/10)
additional amount from each paycheck. If you do not complete this form, the
department requires your employer to withhold 2.7% of your gross taxable
wages until your employer receives a completed form from you.
Electing a Withholding Percentage of Zero
You may elect an Arizona withholding percentage of zero if you meet BOTH
of the qualifying conditions for the election. You qualify for the election if: (1)
you had no Arizona income tax liability for the prior taxable year, AND (2) you
expect to have no Arizona income tax liability for the current taxable year.
Note that Arizona tax liability is gross tax liability less any tax credits, such as
the family tax credit, school tax credits, welfare tax credits, or credits for taxes
paid to other states. If you make this election, your employer will not withhold
Arizona income tax from your wages for payroll periods beginning after the
date of your election.
You should be aware that zero withholding does not relieve you from paying
Arizona income taxes that might be due at the time you file your Arizona
income tax return. Keep in mind that in order to elect zero withholding, you
must meet BOTH conditions listed above. Therefore, if you have an Arizona
tax liability when you file your return or if at any time during the current year
conditions change so that you expect to have a tax liability, you should
immediately complete a new Form A-4 and choose a withholding percentage
that is applicable to your situation.
Employee’s Arizona Withholding Percentage Election
Voluntary Withholding Election by Certain Nonresident
Employees
Compensation earned by nonresidents while physically performing work or
services in Arizona for temporary periods is subject to Arizona income tax.
However, under the provisions of ARS §43-403(A)(5), compensation paid to
certain nonresident employees is not subject to Arizona income tax withholding.
These nonresident employees need to review their situations and determine
whether they should elect to have Arizona income taxes withheld from their
wages or compensation. Nonresident employees may request that their
employer withhold Arizona income taxes from their Arizona source compensation
by completing this form to elect an Arizona withholding percentage.
How do I Determine Which Percentage to Elect?
In an effort to assist employees in electing a withholding percentage, the
following simple examples are provided for general guidance. However,
each employee must take into consideration the particular facts of their own
situation and adjust their election accordingly.
If you want to keep your withholding approximately the same as last year,
you can use your federal Form W-2 for 2009 or your last pay stub to calculate
which withholding percentage to elect. For example, if box 1 of federal Form
W-2 shows $40,000 in wages and box 17 shows $1,000 in state income tax
withheld, divide box 17 by box 1 to determine your percentage (1,000 / 40,000
= .025 or 2.5%). In order to keep your withholding the same as 2009, choose
1.8% (40,000 x .018 = 720) and an additional $10.77 per biweekly pay period
(1,000 - 720 = 280 / 26 = 10.77). Be sure to take into account any amount
already withheld for 2010.
ARIZONA FORM
A-4
If you want to withhold more, choose one of the higher percentages or choose
to have an additional amount withheld.
CAUTION: Underwithholding can result in payment of tax due when you
file your Arizona return and/or underpayment penalties.
If you would rather more closely approximate your tax liability from last year,
use your tax liability from your 2009 Arizona income tax return. Divide that
number by the number of paydays in calendar year 2010. This will be the
amount of withholding you will try to have withheld out of each paycheck.
For instance, if your 2009 tax liability was $1,500 and you are paid every two
weeks (26 paydays a year) divide $1,500 by 26 (1,500 / 26 = 57.69). This
is your withholding goal per paycheck. Next, divide your withholding goal by
your biweekly gross taxable wages, $2,000 in this example, to determine the
percentage of withholding to gross taxable wages (57.69 / 2,000 = .028845
or 2.88%). An election of 2.7% would result in $54.00 (2,000 x 2.7% = 54)
withheld for Arizona from each paycheck ($1,404 annually), while electing
3.6% would result in $72.00 (2,000 x 3.6% = 72) withheld for Arizona from
each paycheck ($1,872 annually). Be sure to take into account any amount
already withheld for 2010.
Example: This example assumes these wages are your only income and your employment situation is the same as last year. If you are paid every
two weeks and last year’s federal Form W-2 shows $52,000 in box 1 and $1,800 in box 17, $900 has already been withheld from your paychecks for
2010, there are 13 paychecks remaining in the calendar year, and you want to keep your withholding approximately the same, the following worksheet
shows how to keep your Arizona withholding the same.
Example:
Line 1: Annual gross taxable wages.
Line 2: Number of paychecks per year.
Line 3: Divide line 1 by line 2. This is wages per paycheck.
Line 4: Annual withholding goal.
Line 5: Amount already withheld.
Line 6: Balance of withholding for the calendar year.
Line 7: Number of paychecks remaining in the calendar year.
Line 8: Divide line 6 by line 7. This is your Arizona withholding
goal per paycheck.
Line 9: Percentage: divide line 8 by line 3.
Line 10: Withholding percentage that is less than line 9.
Check this box on line 1 of Form A-4.
Line 11: Multiply line 10 by line 3.
Line 12: Subtract line 11 from line 8. Enter this amount in the
additional amount space on line 1 of Form A-4.
ADOR 91-0041 (6/10)
$52,000
26
52000 / 26 =
$1,800
$900
1800 - 900 =
13
900 / 13 =
Your Calculation:
$2,000
$ 900
$69.23
69.23 / 2000 =
2.7%
3.4615%
2.7% x 2000 =
69.23 - 54.00 =
$54.00
$15.23
Form W-4 (2010)
Purpose. Complete Form W-4 so that your
employer can withhold the correct federal income
tax from your pay. Consider completing a new
Form W-4 each year and when your personal or
financial situation changes.
Exemption from withholding. If you are
exempt, complete only lines 1, 2, 3, 4, and 7
and sign the form to validate it. Your exemption
for 2010 expires February 16, 2011. See
Pub. 505, Tax Withholding and Estimated Tax.
Note. You cannot claim exemption from
withholding if (a) your income exceeds $950
and includes more than $300 of unearned
income (for example, interest and dividends)
and (b) another person can claim you as a
dependent on his or her tax return.
Basic instructions. If you are not exempt,
complete the Personal Allowances Worksheet
below. The worksheets on page 2 further adjust
your withholding allowances based on itemized
deductions, certain credits, adjustments to
income, or two-earners/multiple jobs situations.
Complete all worksheets that apply. However, you
may claim fewer (or zero) allowances. For regular
wages, withholding must be based on allowances
you claimed and may not be a flat amount or
percentage of wages.
payments using Form 1040-ES, Estimated Tax
for Individuals. Otherwise, you may owe
additional tax. If you have pension or annuity
income, see Pub. 919 to find out if you should
adjust your withholding on Form W-4 or W-4P.
Head of household. Generally, you may claim
head of household filing status on your tax
return only if you are unmarried and pay more
than 50% of the costs of keeping up a home
for yourself and your dependent(s) or other
qualifying individuals. See Pub. 501,
Exemptions, Standard Deduction, and Filing
Information, for information.
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure
the total number of allowances you are entitled
to claim on all jobs using worksheets from only
one Form W-4. Your withholding usually will
be most accurate when all allowances are
claimed on the Form W-4 for the highest
paying job and zero allowances are claimed on
the others. See Pub. 919 for details.
Tax credits. You can take projected tax
credits into account in figuring your allowable
number of withholding allowances. Credits for
child or dependent care expenses and the
child tax credit may be claimed using the
Personal Allowances Worksheet below. See
Pub. 919, How Do I Adjust My Tax
Withholding, for information on converting
your other credits into withholding allowances.
Nonwage income. If you have a large amount
of nonwage income, such as interest or
dividends, consider making estimated tax
Nonresident alien. If you are a nonresident
alien, see Notice 1392, Supplemental Form
W-4 Instructions for Nonresident Aliens, before
completing this form.
Check your withholding. After your Form W-4
takes effect, use Pub. 919 to see how the
amount you are having withheld compares to
your projected total tax for 2010. See Pub.
919, especially if your earnings exceed
$130,000 (Single) or $180,000 (Married).
Personal Allowances Worksheet (Keep for your records.)
A
Enter “1” for yourself if no one else can claim you as a dependent
● You are single and have only one job; or
B Enter “1” if:
● You are married, have only one job, and your spouse does not work; or
● Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
兵
A
其
B
C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or
C
more than one job. (Entering “-0-” may help you avoid having too little tax withheld.)
D
D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return
E
E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above)
F
F Enter “1” if you have at least $1,800 of child or dependent care expenses for which you plan to claim a credit
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
● If your total income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three or more eligible children.
● If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible
G
child plus “1” additional if you have six or more eligible children.
H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) 䊳 H
● If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
For accuracy,
and Adjustments Worksheet on page 2.
complete all
● If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed
worksheets
$18,000 ($32,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.
that apply.
● If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
兵
Cut here and give Form W-4 to your employer. Keep the top part for your records.
Form
W-4
Department of the Treasury
Internal Revenue Service
1
5
6
7
OMB No. 1545-0074
Employee’s Withholding Allowance Certificate
䊳
Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Type or print your first name and middle initial.
Last name
2
2010
Your social security number
Home address (number and street or rural route)
3
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. 䊳
Married, but withhold at higher Single rate.
Single
Married
Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
5
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
6
Additional amount, if any, you want withheld from each paycheck
I claim exemption from withholding for 2010, 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.
䊳
If you meet both conditions, write “Exempt” here
7
$
Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(Form is not valid unless you sign it.)
8
䊳
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Date
9 Office code (optional) 10
Cat. No. 10220Q
䊳
Employer identification number (EIN)
Form
W-4
(2010)
Form W-4 (2010)
Page
2
Deductions and Adjustments Worksheet
Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
1
2
3
4
5
6
7
8
9
10
Enter an estimate of your 2010 itemized deductions. These include qualifying home mortgage interest,
charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and
miscellaneous deductions
1
$11,400 if married filing jointly or qualifying widow(er)
Enter:
$8,400 if head of household
2
$5,700 if single or married filing separately
Subtract line 2 from line 1. If zero or less, enter “-0-”
3
Enter an estimate of your 2010 adjustments to income and any additional standard deduction. (Pub. 919)
4
Add lines 3 and 4 and enter the total. (Include any amount for credits from Worksheet 6 in Pub. 919.)
5
Enter an estimate of your 2010 nonwage income (such as dividends or interest)
6
Subtract line 6 from line 5. If zero or less, enter “-0-”
7
Divide the amount on line 7 by $3,650 and enter the result here. Drop any fraction
8
Enter the number from the Personal Allowances Worksheet, line H, page 1
9
Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,
also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10
兵
其
$
$
$
$
$
$
$
Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)
Note. Use this worksheet only if the instructions under line H on page 1 direct you here.
1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)
2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more
than “3.”
1
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 4–9 below to figure the additional
withholding amount necessary to avoid a year-end tax bill.
4
5
6
7
8
9
Enter the number from line 2 of this worksheet
4
5
Enter the number from line 1 of this worksheet
Subtract line 5 from line 4
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed
Divide line 8 by the number of pay periods remaining in 2010. For example, divide by 26 if you are paid
every two weeks and you complete this form in December 2009. Enter the result here and on Form W-4,
line 6, page 1. This is the additional amount to be withheld from each paycheck
Table 1
Married Filing Jointly
If wages from LOWEST
paying job are—
$0
7,001
10,001
16,001
22,001
27,001
35,001
44,001
50,001
55,001
65,001
72,001
85,001
105,001
115,001
130,001
- $7,000 - 10,000 - 16,000 - 22,000 - 27,000 - 35,000 - 44,000 - 50,000 - 55,000 - 65,000 - 72,000 - 85,000 -105,000 -115,000 -130,000 - and over
Enter on
line 2 above
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
$
$
9
$
Table 2
All Others
If wages from LOWEST
paying job are—
$0
6,001
12,001
19,001
26,001
35,001
50,001
65,001
80,001
90,001
120,001
6
7
8
- $6,000
- 12,000
- 19,000
- 26,000
- 35,000
- 50,000
- 65,000
- 80,000
- 90,000
-120,000
and over
-
All Others
Married Filing Jointly
Enter on
line 2 above
0
1
2
3
4
5
6
7
8
9
10
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 using it 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.
If wages from HIGHEST
paying job are—
$0
65,001
120,001
185,001
330,001
- $65,000
- 120,000
- 185,000
- 330,000
and over
If wages from HIGHEST
Enter on
line 7 above paying job are—
$550
910
1,020
1,200
1,280
$0
35,001
90,001
165,001
370,001
- $35,000
- 90,000
- 165,000
- 370,000
and over
Enter on
line 7 above
$550
910
1,020
1,200
1,280
You are not required to provide the information requested on a form that is
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.
HUMAN RESOURCES DEPARTMENT
Instructions for completing the attached I-9 form:
1. Take the I-9 form to your closest NPC campus or satellite center for
verification.
A. Take one document from list A or one document from list B and one
document from list C (see back of I-9, Employment Eligibility
Verification form for lists). Your name should appear the same on all
documents presented.
B. An NPC campus or center manager or their assistant must verify
this form prior to completion by the close of business on the first day
of employment.*
2. Return all forms to Human Resources.
3. Enclose a copy of your documents used to verify the I-9 form.
If you have any questions or need assistance with this form, please contact Human
Resources at 928-524-7473. Thank you for your cooperation.
*It is the employee’s responsibility to ensure work authorization does not expire and to present
current work authorization documents upon request to prevent possible termination.
NORTHLAND PIONEER COLLEGE
DRUG FREE WORKPLACE ACT OF 1988
The Anti-Drug Abuse Act of 1988, popularly known as the “Omnibus Drug Bill’ requires that employers, such
as the College, who contract with or receive grants from federal agencies certify that they will meet certain
requirements for providing a “drug-free workplace.” Employers who fail to meet the drug-free workplace
requirements will face harsh penalties, including ineligibility to receive further grants or contracts.
The Governing Board and Administration believe strongly in the right of employees and students to work and
learn in an environment that is free from drugs and alcohol. The College has taken the following actions to
assure compliance:
1. A drug and alcohol free workplace policy and procedure has been developed and approved by the
District Governing Board.
2. The College has complied with the Drug-Free Workplace Act by taking a position which conforms to
the requirements of the Act.
3. Each employee has access to the College’s position on maintaining a drug and alcohol free work
environment on www.npc.edu or on MyNPC under the Human Resources tab.
Policy 1560 Drug-Free Workplace http://www.npc.edu/node/294#Policy1560
It is the intent and policy of the college to maintain a drug-free and alcohol-free working environment for its
employees and students.
1. Employees are expected and required to report to work on time and in appropriate mental and physical
condition for work. It is the college's intent and obligation to provide a drug-free and alcohol-free,
healthful, safe and secure work environment.
2. The college prohibits the unlawful manufacture, distribution, dispensing, possession or use of controlled
substances and alcohol on college premises, while conducting college business, or at any time which
would interfere with the effective conduct of the employee's work for the college.
3. The college recognizes drug and/or alcohol dependency as illnesses and major health problems. The
college also recognizes drug and alcohol abuses as potential health, safety and security problems.
Employees needing help in dealing with such problems are encouraged to seek help, either through their
own resources or by requesting help or referral through the sources designated in the procedure based on
this policy. Conscientious efforts to seek help will not jeopardize any employee's job.
4. Employees must, as a condition of employment, abide by the terms of this policy and report any
convictions under a criminal drug statute for violation occurring on or off college premises while
conducting college business. A report of a conviction must be made within five (5) days after the
conviction as mandated by the Drug-Free Workplace Act of 1988. ( Rev 3/10/98)
Procedure 2750 Drug-Free Workplace http://www.npc.edu/node/377
Section 1: Purpose and Goal
Northland Pioneer College is committed to protecting the safety, health and well being of all employees and
other individuals in our workplace. We recognize that alcohol abuse and drug use pose a significant threat to
our goals. We have established a drug-free workplace program that balances our respect for individuals with the
need to maintain an alcohol and drug-free environment.
Northland Pioneer College encourages employees to voluntarily seek help with drug and alcohol problems.
The purpose of this policy is to ensure that no employee under any circumstances comes to work under the
influence of drugs or alcohol and to ensure all employees abide by the laws pertaining to alcohol and drug use
while at work. No person may consume or be under the influence of drugs or alcohol while attending classes, at
any official meetings, or while fulfilling employment responsibilities. Employees must conduct themselves in a
responsible and professional manner at all times.
Covered Workers
Any individual who conducts business for the college, is applying for a position or is conducting business on
the college's property is covered by our drug-free workplace policy. Our policy includes, but is not limited to
the President, executive staff, managers, supervisors, full-time employees, part-time employees, off-site
employees, contractors, volunteers, interns, and applicants.
Applicability
Our drug-free workplace policy is intended to apply whenever anyone is representing or conducting business
for the college. Therefore, this policy applies during all working hours, whenever conducting business or
representing the college, while on call, paid standby, while on college property, at college-sponsored events,
and while attending classes and field trips. Exceptions to this policy for special events may be granted with
prior permission.
Prohibited Behavior
The college strictly prohibits the unlawful manufacture, distribution, dispensing, possession or use of controlled
substances and alcohol on college premises or while participating in any college activity. Prescription and overthe-counter drugs are not prohibited when taken in standard dosage and/or according to a physician's
prescription. Any employee taking prescribed or over-the-counter medications will be responsible for
consulting the prescribing physician and/or pharmacist to ascertain whether the medication may interfere with
safe performance of his/her job. If the use of a medication could compromise the safety of the employee, fellow
employees or the public, it is the employee's responsibility to use appropriate human resource procedures (e.g.,
call in sick, use leave, request change of duty, notify supervisor, notify Human Resources Department) to avoid
unsafe workplace practices.
The illegal or unauthorized use of prescription drugs is prohibited. It is a violation of our drug-free workplace
policy to intentionally misuse and/or abuse prescription medications. Appropriate disciplinary action will be
taken if job performance deterioration and/or other accidents occur.
Notification of Convictions
Any employee who is convicted of a criminal drug or alcohol violation must notify the college in writing within
five calendar days of the conviction. The college will take appropriate action within 30 days of notification.
Local, state, and federal contracting agencies will be notified when appropriate.
Searches
Entering the college's property constitutes consent to searches and inspections. If an individual is suspected of
violating the drug-free workplace policy, he or she may be asked to submit to a search or inspection at any time.
Searches can be conducted of college property.
Drug Testing
To ensure the accuracy and fairness of our testing program, all testing will be conducted according to Substance
Abuse and Mental Health Services Administration (SAMHSA) guidelines where applicable and will include a
comprehensive screening test; a confirmation test; the opportunity for a split sample; review by a Medical
Review Officer, including the opportunity for employees who test positive to provide a legitimate medical
explanation, such as a physician's prescription, for the positive result; and a documented chain of custody.
All drug-testing information will be maintained in separate confidential records.
Each employee, as a condition of employment, will be required to participate in post-accident or reasonable
suspicion testing upon selection or request of management. Pre-employment testing may be required for
employees in safety-sensitive areas related to certification or agency requirements.
Prescreening testing may include but is not limited to such substances as amphetamines, cocaine, opiates,
alcohol, and barbiturates. Testing for the presence of alcohol may be conducted by breath or blood analysis.
Testing for the presence of the metabolites of drugs may be conducted by the urinalysis. Post-accident and
reasonable suspicion testing will include a comprehensive analysis.
Any employee who tests positive will be immediately removed from duty, referred to a substance abuse
professional for assessment and recommendations, required to successfully complete recommended
rehabilitation including continuing care. The employee will be required to pass a fitness-for-duty examination
and sign a Return-to-Work Agreement. Upon learning of allegations of non-compliance that may constitute
cause, the President may initiate Due Process Procedure 2755. http://www.npc.edu/node/379
An employee will be subject to the same consequences of a positive test if he/she refuses the screening or the
test, adulterates or dilutes the specimen, substitutes the specimen with that from another person or sends an
imposter, will not sign the required forms or refuses to cooperate in the testing process in such a way that
prevents completion of the test.
Consequences
One of the goals of our drug-free workplace program is to encourage employees to voluntarily seek help with
alcohol and/or drug problems. If, however, an individual violates the policy, the consequences are serious.
In the case of applicants, if he or she violates the drug-free workplace policy, the offer of employment can be
withdrawn. The applicant may reapply after one year and must successfully pass a pre-employment drug test if
they are applying for a safety sensitive position.
If an employee violates the policy, he or she may be subject to disciplinary action and may be required to enter
rehabilitation. Nothing in this policy prohibits the employee from being disciplined or discharged for other
violations and/or performance problems.
Return-to-Work Agreements
Following a violation of the drug-free workplace policy, an employee may be offered an opportunity to
participate in rehabilitation. In such cases, the employee must sign and abide by the terms set forth in a Returnto-Work Agreement as a condition of continued employment.
Assistance
Northland Pioneer College recognizes that alcohol and drug abuse and addiction are treatable illnesses. We also
realize that early intervention and support improve the success of rehabilitation. To support our employees, our
drug-free workplace policy:
•
•
•
•
•
Encourages employees to seek help if they are concerned that they or their family members may have a
drug and/or alcohol problem.
Encourages employees to utilize the services of qualified professionals in the community to assess the
seriousness of suspected drug or alcohol problems and identify appropriate sources of help.
Ensures the availability of a current list of community professionals.
Offers all employees and their family members assistance with alcohol and drug problems through the
Employee Assistance Program (EAP).
Allows the use of accrued paid leave while seeking treatment for alcohol and other drug problems.
Treatment for alcoholism and/or other drug use disorders may be covered by the employee benefit plan.
However, the ultimate financial responsibility for recommended treatment belongs to the employee.
Confidentiality
All information received by the college through the drug-free workplace program is confidential
communication. Access to this information is limited to those who have a legitimate need to know in
compliance with relevant laws and management policies.
Shared Responsibility
A safe and productive drug-free workplace is achieved through cooperation and shared responsibility. Both
employees and supervisors have important roles to play.
All employees are required to not report to work or be subject to duty while their ability to perform job duties is
impaired due to on- or off-duty use of alcohol or other drugs.
In addition, employees and supervisors are encouraged to:
•
•
•
•
Be concerned about working in a safe environment.
Support fellow workers in seeking help.
Use the Employee Assistance Program.
Report dangerous behavior to their supervisor.
Communication
Communicating our drug-free workplace policy to both supervisors and employees is critical to our success. To
ensure all employees are aware of their role in supporting our drug-free workplace program:
•
•
All employees have access to the policy.
The policy will be reviewed in orientation sessions with new employees
[Based on Policy #1560; Rev 01/26/2010]
NEED ASSISTANCE?
If you have a problem with drug or alcohol dependency and wish to get help, you may contact the Director of
Human Resources. Your request for assistance will be held in strictest confidence.
If you prefer to seek assistance through an outside agency you may call:
ASBAIT Employee Assistance Program:
Community Counseling Centers Inc.:
1-800-343-3822
E-mail: [email protected]
Holbrook
Show Low
Winslow
Pineview
928-524-6126
928-537-2951
928-289-4658
928-386-4110
White Mountain Apache Tribe Behavioral Health:
928-338-4811
Community Information and Referral Services:
1-800-352-3792
Revised 6/28/2010
ARIZONA STATE RETIREMENT STATUS FORM
EMPLOYEE INFORMATION
NAME:______________________________________________
NPC ID#___________________
ADDRESS:________________________________________________________________________
CITY, STATE, ZIP:__________________________________________________________________
CAMPUS /CENTER:___________________________ EMPLOYMENT DATE:________________
MOST CURRENT/RECENT EMPLOYER OTHER THAN NPC IS/WAS ______________________
Northland Pioneer College is a member of the Arizona State Retirement System (ASRS). By
state mandate all current plan participants, Full-Time employees, employees who work 20
hours or more per week and Adjunct Faculty that teach 10 credit hours or more, are
required to participate in the retirement system and have a payroll deduction for
withholding to ASRS. (This deduction is matched by Northland Pioneer College)
If you are currently working for another employer, or your past employer was an Arizona State
Retirement System affiliate, you may be considered an ASRS participant and withholding of
contributions must continue with your employment at Northland Pioneer College.
Please mark one of the options below:
_____ 1. I am currently participating in the Arizona State Retirement System through
NPC or another employer.
_____ 2. I am currently retired from the Arizona State Retirement System **
_____ 3. Neither of the above statements applies
**If you marked option 2, please contact our payroll department before
your first day of work to sign a retirement waiver of agreement/acknowledgement
for audit purposes.
If your ASRS withholding status should change during employment with Northland
Pioneer College, please contact payroll to update your information.
FOR OFFICE USE ONLY
___________________________________
Employee Signature
WITHHOLDING ACTIVATED
ENROLLMENT FORM RECEIVED
WAIVER RECEIVED
___________________________________
ASRS VERIFICATION COMPLETE
Date
FOLLOW-UP NEEDED FOR
Social Security #
Contact Human Resources at 928-524-7473 if you require help with this form.
(REVISED 1/28/2010) mb
STATEMENT OF REGISTRATION STATUS
As per Arizona Revised Statutes that became effective September 30, 1998, “a male
person born after December 31, 1960, is not eligible to hold any office, employment, or service
in any public institution in Arizona unless the person has registered with the Selective Service
System.” To comply, please complete the following statement:
I certify that I am registered with Selective Service.
I certify that I am not required to register with Selective Service because:
I am in the armed services on active duty (Note: Does not apply to
members of the Reserves and National Guard who are not on
active duty.)
I have not reached my 18th birthday
I was born before 1960
I am not a citizen of the United States
I am female and am not required to register
Employee’s Signature
Employee Name (Please Print)
Social Security Number
Revised March 2002
Date