FULL TIME BUS OPERATOR 180 Boyden Ave., Maplewood, NJ 07040-2494 `MONTH
YEAR
DAY
/
DATE
PRINT LEGIBLY IN INK
/
PERSONAL DATA SOCIAL SECURITY NUMBER
NAME (Last)
MI
NAME (First)
ADDRESS (Number) (Street) DO NOTUSEA P.O.BOX
-
Date of Birth: ____-____-______
(Apartment Number / Suite)
STATE
CITY
ZIP CODE
FULL E-MAIL ADDRESS
PRIMARY PHONE NO.
SECONDARY PHONE NO.
-
-
-
-
If hired, you will be required to furnish proof that you are legally authorized to work in the United States. Are you legally able to work in the United States? Have you ever been employed by NJ Transit?
Yes
Yes
No No
Position Held:
W hen:
Do you have any relatives working for NJ Transit?
Yes
No
If YES, PLEASE COMPLETE THIS SECTION
NAME:
RELATIONSHIP:
JOB TITLE:
LOCATION:
RELATIVES WILL NOT BE EMPLOYED UNDER DIRECT SUPERVISION OF ONE ANOTHER NOR WILL THEY BE PLACED IN THE SAME DEPARTMENT IF, IN NJ TRANSIT'S OPINION, THIS COULD RESULT IN POTENTIAL CONFLICTS OF INTEREST.
EDUCATIONAL RECORD HAVE YOU
Name, Street, City and State of School
COMPLETED
High School or GED
YES
Diploma/Degree or Credits Earned
Field of Study
NAME
NO
ADDRESS
YES
NAME
NO
ADDRESS
YES
NAME
College
College
Professional or Technical Schools
NO
ADDRESS
YES
NAME
NO YES
ADDRESS
NAME
Graduate NO
ADDRESS
NEW JERSEY TRANSIT IS AN EQUAL OPPORTUNITY EMPLOYER FTPO121916 eem
PAGE 1/5
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APPLICANT HISTORY PLEASE ACCOUNT FOR YOUR TIME DURING THE PAST TEN (10) YEARS, INCLUDING JOBS, SCHOOLING, UNEMPLOYMENT, SELFEMPLOYMENT, MILITARY SERVICE, ETC. IF YOU NEED ADDITIONAL SPACE, PLEASE ASK FOR ADDITIONAL PAGES. MONTH
YEAR
FROM DATE
/
TO DATE
/
SALARY
$
,
.
,
Annually
.
Hourly
Employer's Name Employer's Address
Work Hours
Employer's City
State
Job Title
Name Under Which Employed
______ Zip Code
Duties, You Must Describe Vehicles Driven (If applicable) ______________________________________________________________________________________ Supervisor's Name
Supervisor's Title
Supervisor's Phone No.
Reason For Leaving Were you subject to the Federal Motor Carrier Safety Regulations While Employed? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug and Alcohol testing requirements of the 49 CFR Part 40? Yes
No YEAR
MONTH FROM DATE
/
TO DATE
/
SALARY
$
,
.
,
.
Annually
Hourly
Employer's Name Employer's Address
Work Hours
Employer's City
State
Job Title
Name Under Which Employed
Zip Code
Duties, You Must Describe Vehicles Driven (If applicable) ______________________________________________________________________________________ Supervisor's Name
Supervisor's Title
Supervisor's Phone No.
Reason For Leaving Were you subject to the Federal Motor Carrier Safety Regulations While Employed? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug and Alcohol testing requirements of the 49 CFR Part 40? Yes
No MONTH
YEAR
FROM DATE
/
TO DATE
/
SALARY
$
,
.
,
Annually
. Hourly
Employer's Name Employer's Address
Work Hours
Employer's City
State
Job Title
Name Under Which Employed
Zip Code ________
Duties, You Must Describe Vehicles Driven (If applicable) ______________________________________________________________________________________ Supervisor's Name
Supervisor's Title
Supervisor's Phone No.
Reason For Leaving Were you subject to the Federal Motor Carrier Safety Regulations While Employed? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug and Alcohol testing requirements of the 49 CFR Part 40? Yes
No
FTPO121916 eem
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APPLICANT HISTORY PLEASE ACCOUNT FOR YOUR TIME DURING THE PAST TEN (10) YEARS, INCLUDING JOBS, SCHOOLING, UNEMPLOYMENT, SELFEMPLOYMENT, MILITARY SERVICE, ETC. IF YOU NEED ADDITIONAL SPACE, PLEASE ASK FOR ADDITIONAL PAGES. MONTH FROM DATE
YEAR
SALARY
$
, Annually
TO DATE
.
,
/
.
Hourly
/
Employer's Name Employer's Address
Work Hours
Employer's City
State
Job Title
Name Under Which Employed
______ Zip Code
Duties, You Must Describe Vehicles Driven (If applicable) ______________________________________________________________________________________ Supervisor's Name
Supervisor's Title
Supervisor's Phone No.
Reason For Leaving Were you subject to the Federal Motor Carrier Safety Regulations While Employed? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug and Alcohol testing requirements of the 49 CFR Part 40? Yes
No YEAR
MONTH FROM DATE
/
TO DATE
/
SALARY
$
,
.
, Annually
. Hourly
Employer's Name Employer's Address
Work Hours
Employer's City
State
Job Title
Name Under Which Employed
Zip Code
Duties, You Must Describe Vehicles Driven (If applicable) ______________________________________________________________________________________ Supervisor's Name
Supervisor's Title
Supervisor's Phone No.
Reason For Leaving Were you subject to the Federal Motor Carrier Safety Regulations While Employed? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug and Alcohol testing requirements of the 49 CFR Part 40? Yes
No MONTH
YEAR
FROM DATE
/
TO DATE
/
SALARY
$
,
.
,
Annually
.
Hourly
Employer's Name Employer's Address
Work Hours
Employer's City
State
Job Title
Name Under Which Employed
Zip Code
Duties, You Must Describe Vehicles Driven (If applicable) Supervisor's Name
Supervisor's Title _______
Supervisor's Phone No.
Reason For Leaving Were you subject to the Federal Motor Carrier Safety Regulations While Employed? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug and Alcohol testing requirements of the 49 CFR Part 40? Yes
No
PAGE 3/5 FTPO121916 eem
DATE AVAILABLE
/
MINIMUM SALARY ACCEPTABLE
/
,
$
.
SKILLS & you to apply (Please each position that you are applying for by filling What led to indicate NJ TRANSIT? (Circle One) Ad Agency EXPERIENCES Employee
Annually
Hourly
in the appropriate to that position.) Job Fair circle next Walk-in
Internet
Other
001 - PT - Bus Operator
201 - Ticket Vending Machine Maintainer
312 - Accounting / Finance
002 - PT - Ticket Agent
202 - Laborer
313 - Nurse
Please specify the Ad, Agency, Job Fair, Walk-in, Employee, Internet, Other: __________________
List residences forClerk the last three years dates lived at each address. 003 previous - PT - Transit Information 203 -(3) CAM (Railand Cargive Cleaner) 314 - Medical Technician Street Address City State Zip Dates Resided
101 - Machinist
204 - Bus Cleaner
315 - Public Relations
102 - Mechanic
205 - Car Inspector (Train)
316 - Paralegal
103 - Pipefitter
206 - Assistant Conductor
401 - Supervisor - Maintenance
104 - Bus Service Person
207 - Locomotive Engineer
402 - Supervisor - Operations
105 - Bus Mechanic
301 - Clerical
405 - Human Resources
106 - Electrician
302 - Administrative/Secretarial
406 - Doctor
Additional Disclosures
All Bus Operator Applicants: The information you provide regarding your current or previous employers will be used, and your current or previous employers will be contacted, for the purpose of investigating your safety performance history information as required by FMCSA regulations. As a prospective driver employee, you have the following rights regarding the information provided to NJ TRANSIT by your current or previous employers:
The right to review information provided by previous employers; The right to have errors in the information corrected by the previous employer and for that previous employer to resend the corrected information to NJ TRANSIT; The right to have a rebuttal statement attached to the alleged erroneous information, if you and your previous employer cannot agree on the accuracy of the information.
PAGE 4/5 FTPO121916 eem
ALL SECTIONS MUST BE COMPLETED TO BE CONSIDERED FOR EMPLOYMENT
DRIVER’S LICENSE INFORMATION – All Licenses or Permits Held Within the Past 3-Years Issuing State
License Number
Type/Class/ Endorsements/ Restrictions if Any
Expiration Date
Have Any of the Above Listed License(s) or Permits Been Suspended/ Denied/ Revoked? If YES, Please Complete the Information Below:
Yes
No
When?
Reason
From
To
Please list all motor vehicle accidents you have been involved in during the past three (3) years Date of accident
Nature of accident
Any fatalities or personal injury?
Do you have any Motor Vehicle Offenses and/or Convictions? Yes
If YES, list all violations (except parking) for which you were convicted, o r forfeited bond or collateral in the past 3 years. All applicants will be thoroughly investigated. Therefore, any omission or willful mis-statement will be cause for disqualification for employment. DATE DATE OF VIOLATION
DATE OF CONVICTION
OFFENSE
DISPOSITION AND FINE
(Forfeited Bond, Collateral, Points, etc.)
NAME OF COURT AND LOCATION
1 2 3
APPLICANT'S CERTIFICATION, AGREEMENT & AUTHORIZATION This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. I understand that if I provide any misleading or incorrect information during the employment process it may render this application void and result in my immediate termination if the misleading or incorrect nature of the information is discovered if and after I am employed. I hereby authorize my former employers to release any information they may have concerning my employment with them and hereby release NJ TRANSIT (hereinafter the “Company”) and all previous employers listed above from all liability whatsoever that may ensue from providing or securing this information. I further authorize representatives of the Company to take all reasonable actions to verify any and all information contained herein and to obtain and review any and all criminal history, driving and disciplinary records of any sort that may exist concerning me. If the Company employs me, I agree to conform to the rules and regulations of the Company. I understand that if I am employed in a position not covered by a labor agreement, my employment will be “at will”, and that my employment can be terminated at any time, with or without cause and with or without advance notice, by either the Company or myself. Moreover, as a non-agreement employee, I understand that no manager or representative of the Company, other than the Executive Director of NJ TRANSIT, or the Executive Director’s Designee, has any authority to make an offer of employment, and/or to make any agreement with me contrary to or different than the terms contained in this affidavit and authorization. I understand that if I am employed in a position covered by a labor agreement and successfully complete the probationary period prescribed by such agreement, NJ TRANSIT may terminate my employment in accordance with the provisions of the applicable labor agreement. It is the Company’s policy to hire and promote without regard to race, color, creed, sex, age, national origin, religion, veteran status, handicap and sexual orientation or any other status protected by law. I agree that I will support such a policy if the Company employs me. I understand and agree that all employment offers are contingent upon successful completion of the pre-employment process that includes a comprehensive background check, including criminal history and driving record check, and an employment physical that may include a test to determine the presence of drugs and/or alcohol in my body.
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DATE FTPO121916 eem
Signature
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