Application

Name

First Middle Last

Address

Street Address City State ZIP Code

List States other than Michigan which you have been a resident of

Home Phone

Cell Phone

List any previous last names

Social Security Number

Driver's License Number

Position Applying For

Can you perform the essential functions of this job with or without accommodations?

Yes

[Please reference job description]

List type of drivers’ license and any endorsements to your license

Do you have any points on your driver’s license?

Yes

List all convictions of motor vehicle laws for the past 3 years.

Have you ever been convicted of a felony?

Yes

Describe in detail – include city and state.

Are you currently working?

Yes

Have you worked for us before?

Yes

Do you have any relatives employed at Bay Metro?

Yes

List name(s) of the relative(s)

Are you prevented from lawfully becoming employed in this country because of VISA or immigrant status?

Yes

Are you a veteran of the armed forces?

Yes

Branch

Rank

Dates of Service

Are you 18 years of age or older?

Yes

Have you ever been disciplined, discharged or given the option to resign from a job?

Yes

Explain

Will you submit to a pre-employment drug & alcohol testing?

Yes

Have your failed or refused a DOT drug &/or alcohol test in the previous 2 years?

Yes

EMPLOYMENT: Please list current employer[s] and ALL previous employers for the last 10 years. Start with current or most recent. Include active or reserve military experience.

Current Employer name

Address

Street Address City State ZIP Code

Employed From

MM slash DD slash YYYY

Employed To

MM slash DD slash YYYY

Type of Employment

Full-time

Part-time

Temp

Supervisors Name

Phone

Position Held

Duties Performed

Reason for Leaving

Employer Name

Address

Street Address City State ZIP Code

Employed From

MM slash DD slash YYYY

Employed To

MM slash DD slash YYYY

Type of Employment

Full-time

Part-time

Temp

Supervisors Name

Phone

Position Held

Duties Performed

Reason for Leaving

Employer Name

Address

Street Address City State ZIP Code

Employed From

MM slash DD slash YYYY

Employed To

MM slash DD slash YYYY

Type of Employment

Full-time

Part-time

Temp

Supervisors Name

Phone

Position Held

Duties Performed

Reason for Leaving

Employer Name

Address

Street Address City State ZIP Code

Employed From

MM slash DD slash YYYY

Employed To

MM slash DD slash YYYY

Type of Employment

Full-time

Part-time

Temp

Supervisors Name

Phone

Position Held

Duties Performed

Reason for Leaving

EDUCATION: Include all high schools, colleges, trade schools

High School

Address

Street Address City State

Did You Graduate?

Yes

Did you receive a GED?

Yes

College/Trade School

Address

Street Address City State

Did You Graduate?

Yes

Degree/Certification Received

Field of Study

College/Trade School

Address

Street Address City State

Did You Graduate?

Yes

Degree/Certification Received

Field of Study

REFERENCES: List three [3] persons not related to you who have knowledge of your character, experience and ability.

Name

Phone

Address

Street Address City State

Title/Position

Name

Phone

Address

Street Address City State

Title/Position

Name

Phone

Address

Street Address City State

Title/Position

PLEASE READ CAREFULLY Bay Metro is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, religion, ancestry, age, sex, genetics, marital status, national origin, disability or handicap, height, weight, veteran status or any other reason prohibited by law.

APPLICANT’S CERTIFICATION AND AGREEMENT

AGREEMENTS: “I understand that the employment relationship at the Authority is ‘at will’, meaning that it may be terminated by myself or the Authority at any time with or without notice and with or without cause. I also understand that no other statement, made orally or in writing, may change this at will relationship unless expressly stated in a document signed by both the Authority’s General Manager and by me stating that the at will relationship has been modified. I agree that, in applying for a position with the Authority, I am willing to accept employment, if offered, based on these terms.”

“I agree that any action or suit against the Authority, its agents or employees, arising out of my employment or termination of employment, including, but not limited to, claims arising under State, but not Federal, civil rights statutes, must be brought within 180 days of the event giving rise to the claims or be forever barred. I waive any limitation periods to the contrary. I further agree that if I should bring any non-statutory action or claim arising out of my employment against the Authority, in which the Authority prevails, I will pay to the Authority any and all such costs incurred by the Authority in defense of said claims or actions, including attorney fees. I further agree that my employment is conditional until such time as the results of my post offer physical, drug and alcohol tests are known.”

PROBATION PERIOD: It is understood that I shall be considered as on a temporary basis during a probationary period of 6 months/180 days from date of hiring and may be discharged or laid off before the expiration of the period without recourse.

STATEMENT BY APPLICANT: I hereby authorize my former employers to furnish their records of any service, my reason for leaving their employ, together with all information they may have concerning me, whether on record or not. I also release them and their company, from any liability for any damage whatsoever for issuing same.

It is agreed that any misrepresentations by me, in this application, will be sufficient cause for its cancellation or for dismissal from the authority if I am employed.

I hereby certify the facts set forth in the above employment application are true and complete to the best of my knowledge. You are hereby authorized to make any investigation of my personal history and financial and credit record through any investigative or credit agencies or bureaus of your choice.

*NOTE: The provisions of the Fair Credit Reporting Act may be applicable if a credit report on the applicant is obtained and considered.

Signature

Date

MM slash DD slash YYYY

VOLUNTARY SELF-IDENTIFICATION OF A DISABILITY

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment. Why are you being asked to complete this form? As an employer/government employer we must reach out to hire and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. Any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way. You may voluntarily self-identify as having a disability on this form without fear of any discrimination. How do I know if I have a disability? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

Blindness
Autism
Bipolar disorder
Posttraumatic stress disorder (PTSD)
Deafness
Cerebral palsy
Major depression
Obsessive Compulsive Disorder
Cancer
HIV/AIDS
Multiple sclerosis (MS)
Impairments requiring the use of a wheelchair
Diabetes
Epilepsy
Schizophrenia
Muscular dystrophy
Missing limbs or partially missing limbs
Intellectual disability (previously called mental retardation).

Please select one of the statements below:

YES, I HAVE A DISABILITY (or previously had a disability)

NO, I DON’T HAVE A DISABILITY

I DON’T WISH TO ANSWER

For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

APPLICANT DATA RECORD

Applicants and Employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or
handicap/disability, or any other legally protected status.

We comply with government regulations, including affirmative action responsibilities where they apply. Solely to help us comply with governmental record keeping, reporting and other legal requirements, we request that you please fill out the Applicant Data Record. We appreciate your cooperation.

This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.

YOUR COOPERATION IS VOLUNTARY.

Various government agencies request statistical information regarding our hiring practices. Your cooperation in completing this form is completely voluntary. Any information gathered is strictly confidential and will not subject you to coercion or intimidation relating to your status.

Failure to provide this information will not adversely affect your application. Thank you for your cooperation.

Check one

Male

Female

Check one of the following Race/Ethnic groups

Hispanic or Latino

Other

If other, check one of the following Race/Ethnic groups

White

Black or African American

Two or more Races

Native Hawaiian or Other Pacific Islander

Asian

Native American Indian / Alaskan Native

Check if any of the following are applicable

Vietnam Era Veteran

Disabled Veteran

Pre-Employment Physical, Drug & Alcohol Testing Consent

I, herby give my consent to Bay Metro Transit Authority to perform the appropriate test(s) to identify the presence of drugs and alcohol. I furthermore give my permission for the test results to be released to Bay Metro Transit Authority.

I understand that refusal to take this test, attempts to adulterate the sample, or a positive test for illegal drug use will result in Bay Metro Transit Authority withdrawing my job offer that was contingent on passing the pre-employment physical, drug and alcohol test or terminating my employment.

Signature

Date

MM slash DD slash YYYY

Background Investigation Consent

I authorize Bay Metro Transit Authority to investigate all statements contained in my employment application, including records of any current and former employers, police departments, and other references or sources concerning me including a credit check. I authorize all such references and sources, as well as Bay Metro Transit Authority, to release this information without liability for damages incurred in giving it. I waive any written notice of the release of such records that may be required by state or federal law.

Signature

Date

MM slash DD slash YYYY

Name

First Middle Last

Address

Street Address City State ZIP Code

List States other than Michigan which you have been a resident of

Home Phone

Cell Phone

List any previous last names

Social Security Number

Driver's License Number

Position Applying For

Can you perform the essential functions of this job with or without accommodations?

Yes

[Please reference job description]

List type of drivers’ license and any endorsements to your license

Do you have any points on your driver’s license?

Yes

List all convictions of motor vehicle laws for the past 3 years.

Have you ever been convicted of a felony?

Yes

Describe in detail – include city and state.

Are you currently working?

Yes

Have you worked for us before?

Yes

Do you have any relatives employed at Bay Metro?

Yes

List name(s) of the relative(s)

Are you prevented from lawfully becoming employed in this country because of VISA or immigrant status?

Yes

Are you a veteran of the armed forces?

Yes

Branch

Rank

Dates of Service

Are you 18 years of age or older?

Yes

Have you ever been disciplined, discharged or given the option to resign from a job?

Yes

Explain

Will you submit to a pre-employment drug & alcohol testing?

Yes

Have your failed or refused a DOT drug &/or alcohol test in the previous 2 years?

Yes

EMPLOYMENT: Please list current employer[s] and ALL previous employers for the last 10 years. Start with current or most recent. Include active or reserve military experience.

Current Employer name

Address

Street Address City State ZIP Code

Employed From

MM slash DD slash YYYY

Employed To

MM slash DD slash YYYY

Type of Employment

Full-time

Part-time

Temp

Supervisors Name

Phone

Position Held

Duties Performed

Reason for Leaving

Employer Name

Address

Street Address City State ZIP Code

Employed From

MM slash DD slash YYYY

Employed To

MM slash DD slash YYYY

Type of Employment

Full-time

Part-time

Temp

Supervisors Name

Phone

Position Held

Duties Performed

Reason for Leaving

Employer Name

Address

Street Address City State ZIP Code

Employed From

MM slash DD slash YYYY

Employed To

MM slash DD slash YYYY

Type of Employment

Full-time

Part-time

Temp

Supervisors Name

Phone

Position Held

Duties Performed

Reason for Leaving

Employer Name

Address

Street Address City State ZIP Code

Employed From

MM slash DD slash YYYY

Employed To

MM slash DD slash YYYY

Type of Employment

Full-time

Part-time

Temp

Supervisors Name

Phone

Position Held

Duties Performed

Reason for Leaving

EDUCATION: Include all high schools, colleges, trade schools

High School

Address

Street Address City State

Did You Graduate?

Yes

Did you receive a GED?

Yes

College/Trade School

Address

Street Address City State

Did You Graduate?

Yes

Degree/Certification Received

Field of Study

College/Trade School

Address

Street Address City State

Did You Graduate?

Yes

Degree/Certification Received

Field of Study

REFERENCES: List three [3] persons not related to you who have knowledge of your character, experience and ability.

Name

Phone

Address

Street Address City State

Title/Position

Name

Phone

Address

Street Address City State

Title/Position

Name

Phone

Address

Street Address City State

Title/Position

APPLICANT’S CERTIFICATION AND AGREEMENT

Signature

Date

MM slash DD slash YYYY

VOLUNTARY SELF-IDENTIFICATION OF A DISABILITY

Blindness
Autism
Bipolar disorder
Posttraumatic stress disorder (PTSD)
Deafness
Cerebral palsy
Major depression
Obsessive Compulsive Disorder
Cancer
HIV/AIDS
Multiple sclerosis (MS)
Impairments requiring the use of a wheelchair
Diabetes
Epilepsy
Schizophrenia
Muscular dystrophy
Missing limbs or partially missing limbs
Intellectual disability (previously called mental retardation).

Please select one of the statements below:

YES, I HAVE A DISABILITY (or previously had a disability)

NO, I DON’T HAVE A DISABILITY

I DON’T WISH TO ANSWER

APPLICANT DATA RECORD

Check one

Male

Female

Check one of the following Race/Ethnic groups

Hispanic or Latino

Other

If other, check one of the following Race/Ethnic groups

White

Black or African American

Two or more Races

Native Hawaiian or Other Pacific Islander

Asian

Native American Indian / Alaskan Native

Check if any of the following are applicable

Vietnam Era Veteran

Disabled Veteran

Pre-Employment Physical, Drug & Alcohol Testing Consent

Signature

Date

MM slash DD slash YYYY

Background Investigation Consent

Signature

Date

MM slash DD slash YYYY

Application

application

APPLICANT’S CERTIFICATION AND AGREEMENT

VOLUNTARY SELF-IDENTIFICATION OF A DISABILITY

APPLICANT DATA RECORD

Pre-Employment Physical, Drug & Alcohol Testing Consent

Background Investigation Consent

APPLICANT’S CERTIFICATION AND AGREEMENT

VOLUNTARY SELF-IDENTIFICATION OF A DISABILITY

APPLICANT DATA RECORD

Pre-Employment Physical, Drug & Alcohol Testing Consent

Background Investigation Consent

Requesting a Reasonable Modification

COMMUNITY RESOURCES