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NEW YORK CITY BOARD OF EDUCATION DIVISION OF HUMAN RESOURCES 65 Court Street, Brooklyn, New York 11201 APPLICATION TO ATTEND MEETING, CONFERENCE OR CONVENTION OUTSIDE NEW YORK CITY Please read General

Number Job and Work Status Education (or completion date) Date of Birth, Marriage, Current Occupation. I certify that person answering all questions is either: (i.a) A New York State resident with a valid New York State driver's license number; (ii.a) At least 18 years old; and (iii.a) Currently employed as provided for in this application and if the applicant is an independent contractor (contractor). I believe this application meets the general requirements for the position stated above and that I have all the information required for my application to advance my eligibility for employment as an employee of: (i) An Employer with a Business, Subsidiary of an Employer, or the spouse or dependent of a person described in item (ii); (ii) A New York State or State-funded program that operates under section 21 of the Employee Retirement Income Security Act of 1974, [29 U.S.C.], as amended [28 U.S.C.]; (iii) An employer with a bona fide plan to distribute any of an employee's annual earnings, as determined primarily by the employee's contributions (or the employee's beneficiaries' contributions) to such a plan and a plan operated by a member of the employee's family, if (i) such earnings are subject to retirement benefit deductions; (ii) the plan is established and maintained primarily for the benefit of the employee and his or her beneficiaries through contributions made on the employee's behalf as provided in regulations of the Secretary of Labor, under part 6 of title 7 [29 U.S.C.]; and (iii) such plan is operated by a member of the employee's family; (iv) An eligible person as defined in regulations prescribed by the Commissioner of Social Security; or (v) An eligible other than an eligible person as defined in regulations prescribed by the Commissioner of Social Security; (vi) An eligible dependent as defined in regulations prescribed by the Commissioner of Social Security; or (vii) An eligible person not specified in paragraph (a)(1) above to the extent that the employee's work location is outside New York City; (viii) An eligible spouse who is not the employee's dependent (as provided for in section 401(a) of the Internal Revenue Code); and (ix) An eligible dependent who is not the employee's spouse (as provided for in section 101(a) of the Internal Security Code). II.

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