PAYROLL CHANGE FOR! NAME: Michael Ledbetter 8.5, ¥ | NAME CHANGE, INDICATE FORMER HAM) ‘ADDRESS: DEPARTMENT: ACCT #: ‘SCHOOL: DEGREE: YEARS EXPERIENCE: EFFECTIVE DATE: December 13, 2017 BACKGROUND CHECK STATUS: CUREPORT ATTACHED IREPORT WILL BE FORWARDED INDICATE ALL APPLICABLE CHANGES: HIRED Oruu-time STARTING WAGES COPART-TIME COTERMINATED LEAVE OF ABSENCE: DOTRANSFER CNAME CHANGE FROM____TO. DOREHIRED CLADDRESS CHANGE SALARY CHANGE: DRETIRED © oTHER FROM To. ORESIGNED New Exployee Hire - Bus Driver - substitute - effective December 13, 2017. January 12, 2018 Cy oan ie THIS FORM MUST CONTAIN COMPLETE AND AccCURATE ust ‘COMPLETED EACH TIME THERE 1 A CHANGE OR PERSONNL INCLUDING NAME CHANGE, DEGREE CHANGE, OR POSITION CHANGE, (vise 7-2-2008) ‘eword/peyrlihangstormTRANSPORTATION DEPARTMENT APPLICATION Rhea County Department of Education 305 California Avenue, Dayton, TN 37321 (423) 775-7813, 7812, 7814 Mac. Woywe ledbeket pate ¥-2¢- 17 City oa State Zip R7ZQI Birthdate _/~)?~ 60 Name (full) Address Phone # ‘Type of Job applying for _{ EDUCATIONAL BACKGROUND: (Begin with high school ~or- Supply copy of GED diploma) ‘School / Location Graduation Date [ Diploma/Degree | Special Stilis avy. GED, WORK EXPERIENCE: (List in order, beginning with most recent) ‘Employer/Address Position Dates (from/to) | Salary aa = HAS Seue Eapleoyeal eats gt 10:00 (a.20tmnais Asyntisy | da13 to 1i-K|//-3= F8| Nedsdic Colar © pemlies recy 19-96-02 Wold) PY Foo A] REFERENCES: (Employees, Principals, Teachers or Friends; no Relatives) Name Address Phone # Position SKILLS: (List any skills you have to help you perform this job effectively) Have you any physical defect, or affected by any other ailment in which you may need special accommodation to perform the essential functions of the position you are applying for? Yes Noy If yes, please explain: Have you ever been convicted of a crime? Yes No wa **#* If yes, please explain on the back of this page, Are you a Citizen of the United States: Yes _ 2X No I authorize the release of all information regarding myself to Rhea Co. Department of Education. sina Meta Loalbartter We are an equal opportunity employer. Prospective employecs will reccive consideration without discrimination of race, creed, color, sex, age, handicap, or national origin. Grievance contact person: Mr. George Thacker (423) 775-7801Pepartinen of Jue un He 11154136 wert ad Matalin Service Employment Eligibility Verification en ere ere rere eee ener] ease read instructions carefully before completing this form. The Insiructions must be available during completion this form. ANTHDISCRIMINATION NOTICE: {tis tlegal to discriminate against work eligible individuals, nptoyers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an dual because of a (uture expiration date may also constitute ilegal discriminati Employee | mation and Ver fon. To be compsce wna signed by erpleyee atthe Ue emp Sr ide tata | Maiden ae “Reolhettce Miclivel ‘Bate of Bith day =/G civ aveie that federal law provides Tor Ta Sar rahy of TO prisonment and/or fines for false statements or Eps btn vata ofthe Untied Sete, 2 of false documents in connection with the ena -npletion of this fore, pierre iors SRS STAT Ge 3 Preparer and/or Le i Tonihcaton "be completa and signed f Secu 1 Ts pared By a person ‘other ian the employee, | attest, under pany of pap. at Ihave assed inthe completion ef this fara Oat tO the _st of mp Anwrrge the lft 1 tae an caret Signe Pant Rare (Set Namo arid Nuuvibor, Cky, State. Dp Codey Date noathitayiyeoed fon 2. Employer Review and Verification, Ye be compte ine ona docurent from Lt 8 and one from tat C, ne Hated om the reverse of hie farm, and record the te, number and expiration date, if wny, Bf the pent List A vg authority; <= eee spation Davy Om iret ata anyh? IFICATION <1 test, under penalty of perjury, that I have examined the document(s) presented by the above-named 2yee, that the above-listed document(s) appear to be geruine and to relate to the employee named, that the 2yee' began employment on (imandhiday/yabr) I. J. aeW trat Lo the best of my knowledge the ible to Work in the United States. (State empléyment agencies may omit the date the employee began symment) tu of Cnplavere Rhortod Represartative | Pat Name i Sie or Grganiaiion Nao ‘Rasvoss (Sveat Nome and Hamber Oty, Slate, Zp Goda) | Bate (movth/eayivear) ion 3. Updating and Revert ication, To-be completes ond sed by mye B. Bate of hive fmonthtdayiyea) Of eppieabie) as i aman BE a RTT ak CRANES COON OTS Docueren epralon Date (any)! ‘he Bost af my tnowiadge, th ormpioyoe lige to work the United States, ond W the empiayee preseniod Sint), tha eocumern) have examined anpnar to be gentane and treats tothe lacus tre of Employer or Authorzed Reprosantative Bate Tronth aavTpoed Torn 8 hen ALS Paps?