EMPLOYMENT APPLICATION Position Appliag for __— Date: Bay Site Transit Services considers al epalicens fo employment without regard o rece, color, religion, cox, national crigin, ‘age, hancicap or disabilty, or slats as a Vieinam-era or special disabled veleran hn accordance wih federal law. In adn, 8875 complies wih applicable state ard local laws prohibiting discrimination in erploymentin every jursdiction in which it ‘maintains fects. Bay Stato Transit Services also provides ‘reasonable ascommodatons" lo qualified indliduae with clsabiities, in accordance with fhe Americans With Desabities Act and applicable state and ncal ews, We invite all disabled indiviuals who need assistance in the application or employment process to advise the Humman Resource Office of hat ned ard ‘suggest ths kind of accommodation thet Wout 86 eppropriata, Name Social Security No. Curent Adress: Stet. ony Stte_______ZIP Code: Telephone No. Referred by_ Aro you 18 years of age or older? —[ J¥es [ ] No ‘Ae you wiing fo work ovattine asnecessary? [ | Yes [ ] No Dale you can cat {s there anything that would prevent you from performing in a reascnable and safe manner the actives involved in the position for wtich you have appod? { 1¥es{_ 1No Ifyes, please explain: Have you ever been convicted of acrre?* { Yes | |No Ife, sate nature of offense, when, where, ard dagositon,_ "kcomicion record wil rol necessarily be abar to employment. This formation wil be used only for jeb-elated purposes anc only tothe extent permitted by applicable law. Federal laws requir thal employer hire only indviduas who are autorize tobe awfly employed in he United States. In compiance wit such laws, al offs of employment are subject to verifcaton ofthe applicant's identy and employment authorization, and it wil ba necessary for you to submit such documents as ere aquired bylaw to verily your identification and employment authorization upon employment. Are you authoriza¢ to work forall employer in the United Stas ona fulltime basie,o ony for your curent employer? [J llamployers. |] Curent employer only RECORD OF EDUCATION Reoetved Type Number of Yours Degree of Namo and School Address Attended MaiorMincr _YesNo Degree fi L 7 Z f i L L L f f nPRIOR WORK HISTORY (Lisl in order, lst or curent employer fst.) Account for any gaps in your employment (1) Company Name Phonet Adress Employed From: To Position Reason for Leaving: ast Wage: Describe in detail fe work you performed (2) Company Nama: Cl ness Empoyes From: To Psion: Reason for Leaving. Last Wage Describe in detail the work you performed (3) Company Mania Phonge{ Atos. Employed Fromm To Positon: Feasan for Leaving Last Wage: DDescite in detail the work you pertarmed, (8) Company Name: Phone { oy es: Employed From: To Position Reason for Leaving Lastviage (Deserve in deta the work you performed, (5) Company Narne: Phone. { Adress: Employed From: To Poston: Reason for Leaving Last age Describe in deal fhe work you performed. Page 2 HR Form 001 0820199MILITARY SERVICE RECORD ‘Have you ever served in the US. Armed Forces? [ | Yes [1 No Ust duties in the Service, incluaing special \Waining thats relevant to the pasiion for which you have applied. LANGUAGES ‘seen ad vee ty Gad umn Goud Ft enh Goad Fay oo poy ot tL t i ! L t PROFESSIONAL LICENSEICERTIFICATION OR REGISTRATION DATA, cense Number Tye State Expirafon Date (Ucense Number Type _ State Expiration Date Loon Number, Type. Sale Expration Date LGoense Number Tre. Sista Expiration Date ‘SPECIFIC SKILLS AND EXPERIENCE OATES PERFORMED FROM IO DESCRIPTION OF SKILLS AND EXPERIENCE WHERE DID VOU OBTAIN EXPERIENCE Page 3 HR Form 001 982099PREEMPLOYMENT STATEMENT (Please vead carefully and sign the statement De/ow) ‘understand and agree that. ‘erty that al statements made on this application for employment are true ancl correct to the best of my knowtedpe and best, ‘and [understand that any miseepresentation or omission of material faci on the application or during any interviews, may be |ustiteston of refusal of employment, or, I employed, ermination from Bay States Trans Services employ. [hereby apply for eiployment with tis Company and | aufirize Bis Company to conduct a background investigation and agree ta sooperat in such Investigation; to vert any of the stalements made, o sot information desred in connection wit Bs apical, incuding mates of ophion relating to character, ably, and past conduct. | suthorie each incivkuel anc ‘organization named above to release such information; and release from al ably o responsibilty all persons, companies or ‘organizations supplying such information [Any offer of employment mar receive from BST is contingent upon my successful complaton of the company’s lta pre= ‘employment screening process, including the company’s recelvng references that It considers safsteciory, and my saifactory completion a any post-fier pre-employment medical examination thatthe company may require. | also agree, Femployed, to submit @ medical examination a ay te a the company’s requeet. | herkby consent tb having the resus cf any post-ofer re-employment or pot-ameioyment medical exams | may be required o take disclosed to BST, [understand that as a condition of employment, | may be required to undergo and suocessfuly pass a screening for alcohol ‘andlor drugs. | also understand and agroe that emipioyed, | may be required io submit to an alcohol or drug screening at any {ime atthe elacretion of BST. | hereby consent to heving the results of any such aloonol or drug sereering | may be required to ‘undergo disclosed to BST. In compliance withthe Immigration Reform and Contol Act of 1886, | understand thet wl be required to provide approved documentation thet verfes my right io wok inthe United States on my fst day of employment. (0, vad diver’ icense and ‘social securly card) ‘Signature: Date: Page 4 HR Form 001 08/20/99EMPLOYMENT APPLICATION APPLICANT EEO DATA FORM. Float and Ste agence periodically reuse ha wo supply ham wath nfnTatioa epg The wx, race, Ueabaity and vet asf sae appl Thetov we ae requasting ha You provi ws wal the lowing norman we ca eet ‘eprting reqrements, ‘This nfomation onside Company Cnfidaial and wil ony Be wid fo veri parpoes. Vour “meta hs on ey Vay Name: _ (Company, Social Security Number; fies White ‘ot aF Hispanic origin.) A pores avin egies In my te ign peopl of Lope. Nant Stas ‘Afvica othe Mie East. 1 {vot oF Hispanic origin» AB peas ring cin in anyon rca groups of ic. |) Mspenic A persons Meaican Pri Rican, Cuban, Canal or South American, or Spanish ature xorg, regaetins of AsiaPac ‘An persone having args any of he uigia peoples othe Fr Et Southeast Asin the Ino Tnlander—Suboonlimat orth Pacific Inlnds. This are includes, fr example, China dia, pn, Karen, the ‘Phtppne sland an Sov | mexican nil persons Davie igs any of the aigina poops of Noth Ameri, wd who osha ‘Alkan Native aba etic hw talc o smmsanity eco ‘We invite all pec disabled vsierans, ere OF he Vita ca nd sae itividuals who Betiove they are covered by the ehatilaion Act of 197), and who wih o benefit unde our Afieutive Action Progra, deny thats. Thi ination volun, and wil be Lop condom. Disclosure refwalta povide wil 0 ject you wo any vere kn, a ely Be wd accordance wh Be Act and he rgulaion: Special Disabled (A) A woteran nh eat! compensation (oe who bat the eset af iiay rete ny Ver ‘roa be onided ts competion) ander ln ministered bythe Deparmwat of Veteran « AA Toe ne ebay Red ot Pox We Rak w Doe 10% he cave OF x yteran wn hs ‘een deter under Sano 1806 a Tile 3, (15. tohare wserious employment ania, of (8) a pone who wax dschargod or eeeasd ram acive duty eemne a a ervice-vonneced ‘isa Vietuan Era A veteran any part af whoa ve miliary, nal ir service was ding he prod Aga 5, Veer ‘ne, drag May 7, 197%, hs Served om active ty or prio tare ta {8D ys a ws ‘Sscargel a reletse ert the other thaw dishoomrable Sicha, a was charged or (etext active duty eva of nservice-comneced diay rsa | Yes Wesmenmeaye ou disabled applicants w discus with the Human Resoures department any scones 1 Ne nabs tha o pertanm ther obrmorseliceety and safety Addr. cabled emyplapees ould hx sapere any pol methods, ils ed proves wbich wl ily Wh Tor oss tha Ey ‘aborts eae n do Deca ht daly Applicant Signature a ~ Ba HR FORM 002 ‘4/2099