PRE-QUALIFICATION CHECKLIST Temporary Bridge and Tunnel Officer
Last Name, First Name (please print):
Please read carefully
1. If you answer yes to all the questions below, complete this form and submit with your completed application. 2. If you answer no to any of these questions you are not eligible for this position. If you are not currently eligible, please feel free to apply when you meet the required qualifications stated below. Are you at least 18 years of age? Yes No Do you posses a high school diploma or GED? Yes No Do you posses a valid unrestricted New York State Driver License? Yes No Are you a U.S. Citizen? Yes No Are you a New York State Resident? Yes No Temporary Bridge and Tunnel Officers have work schedules that include rotating tours around the clock and that include work on Saturdays, Yes No Sundays and Holidays. Are you ready, willing and able to work the schedules described above? Temporary Bridge and Tunnel Officers work at the following facilities:
Bronx-Whitestone Bridge Hugh L. Carey Brooklyn-Battery Tunnel Cross Bay Veterans Memorial Bridge Marine Parkway Gil Hodges Memorial Bridge Queens-Midtown Tunnel Yes No Throgs Neck Bridge Robert F. Kennedy Bridge Verrazano-Narrows Bridge
Please review facility locations carefully. Are you ready, willing and able to work at all of the facilities above? I declare, subject to the penalties of disqualification, dismissal even following my employment, and/or prosecution, that the statements made on this document (including the statements made in any accompanying papers submitted by me) have been examined by me and to the best of my knowledge and belief are true and correct.
Applicant’s Signature ______Date ______
EMPLOYMENT APPLICATION
Our Mission Statement
MTA Bridges and Tunnels will provide safe, efficient and courteous service to its customers. We will be the leader in bridge and tunnel management, operations and maintenance, and play a strategic role in the planning and financing of the metropolitan region’s transportation system.
MTA Bridges and Tunnels is an equal opportunity employer (M/F/D/V)
MTA Bridges and Tunnels (legal name, Triborough Bridge and Tunnel Authority) is an agency of the Metropolitan Transportation Authority with the Employment Services Office located at 2 Broadway, 22nd Floor, New York, NY 10004
Verrazano-Narrows Bridge Triborough Bridge Throgs Neck Bridge Bronx-Whitestone Bridge Henry Hudson Bridge Brooklyn-Battery Tunnel Marine Parkway - Gil Hodges Memorial Bridge Queens-Midtown Tunnel Cross Bay Veterans Memorial Bridge
Robert Moses Building 2 Broadway, 24th Floor Randall’s Island, NY 10035 New York, NY 10004 [email protected] Phone No. for the Hearing Impaired: 646-252-7902
Instructions for completing this application: Please take special care in following the instructions that are found below as well as the additional instructions that can be found throughout this application form.
Please:
1. complete this application by printing the answers to each question fully and adequately. 2. provide the full street address of your actual place of residence in sections C-D. Your preferred mailing address, if different than your actual place of residence (for example, a Post Office Box address), should be placed in sections “F-G”. 3. ensure that the full name of each your previous employers is spelled out completely. Please do not use abbreviations or acronyms. 4. do not omit company addresses, supervisors’ names and titles, your own job titles while employed by the company or any other requested employment information. In cases of temporary employment, please provide the names of the companies that you were actually employed by, along with the names of the companies to which you were assigned. 5. ensure that the full name of each education institution is spelled out completely. Again, please do not use abbreviations or acronyms. 6. make sure that all sections of the application are filled in. Requested information that does not apply to you should not be left blank. These boxes should be filled in with “N/A”, “None”, or “0” (as appropriate). 7. sign the application form.
Thank You
Last Name, First Name (please print): Position(s) you are applying for (please print):
Place your initials in the box to the right
Please print clearly and complete sections A-V unless instructed otherwise.
Position(s) you are applying for: Type of position desired: Date Available for Work: Salary Expected: A Full-time Part-time Temporary Last Name: First Name: Mid. Init. Email address (optional):
B Street Address: Additional Street Address Info. (Apt. No., etc.):
C City: State: Zip Code:
D Social Security Number: Residency: E New York City Resident Yonkers Resident Non-N.Y.C./Non-Yonkers Resident Mailing Street Address (if different from above): Additional Mailing Street Address Info. (if different from above):
F Mailing City: Mailing State: Mailing Zip Code:
G Home Telephone (please include area code): Work Telephone (please include area code): Beeper or Cellular Phone (please include area code):
H Are you under 18 years of age? Yes No Are you legally eligible for employment in the United States?
I If yes, do you have working papers providing authorization to work? Yes No Yes No
If yes, what documentation do you have?
Name(s) of relative(s) working at MTA B&T (TBTA), if any If you have ever applied for MTA B&T (TBTA) employment before, please provide position and date. J Have you ever been employed by MTA B&T (TBTA), another MTA agency, a City Agency or a State Agency? Yes No If yes, please complete the following:
K Employment Dates From: To: Title: Agency: ONLY answer “Yes” or “No” to the questions in section “L” if you are applying for a Bridge and Tunnel Officer or Temporary Bridge and Tunnel Officer, or Toll Collector position. If you are NOT applying for a Bridge and Tunnel Officer, Temporary Bridge and Tunnel Officer, or Toll Collector position, check the “N/A” boxes for the questions in section “L”.
L Are you a citizen of the United States? N/A Yes No Do you possess a New York State valid unrestricted driver license? N/A Yes No
Referred to MTA B&T (TBTA) by: Advertisement (Specify): Job Posting (Specify): Employment Agency (Specify): Open House (Specify): College Recruitment (Specify): Other Source (Specify): M Employee (Specify): Phone Inquiry Former Employee (Specify): Unsolicited Job Fair (Specify): Walk-in
Place your initials in the box to the right
Convictions: Have you ever been convicted of an offense other than minor traffic violations? Yes No
If yes, give the arrest date(s), offense(s), name(s) of court(s) and final disposition(s) for all convictions below. Offenses include felonies, misdemeanors and violations (except minor traffic violations). A plea of guilty is a conviction even if you were never imprisoned, only paid a fine, were conditionally discharged or received a Certificate of Relief from Disabilities. If you have a Certificate of Relief from Disabilities, you are still required to list the conviction affected, but may add that you have the certificate. You do not have to disclose any material sealed, expunged or set aside under Federal or State law, or juvenile delinquent or youthful offender adjudications. However, if the original charges for an offense were sealed, but you were subsequently convicted on different charges for the same offense and those charges were not sealed, you must provide the details for the unsealed conviction offense below. Please note that you are not considered a youthful offender just because of your age at the time of the offense. Only a court can determine youthful offender status. If you are unsure about whether or not you were considered a youthful defender, list the offense(s) below and provide details in Section “U” of this N application. You can also use Section “U” to list additional convictions and provide the arrest date(s), offense(s), name(s) of court(s) and final disposition(s) for those convictions as well. A conviction record will not necessarily exclude you from employment. Factors such as age at the time of the offense, rehabilitation efforts, recency and seriousness of the crime will be taken into account. The relationship between the offense and particular jobs will also be weighed. If you list convictions, you may state facts in favor of your employment in Section “U” of this application. A false statement or intentional omission of any material fact on this application may cause you to be disqualified, dismissed even following your employment, and may lead to prosecution.
ARREST DATE LEADING TO CONVICTION OFFENSE NAME AND LOCATION OF COURT SENTENCE AND DATE OF SENTENCE (mm/dd/yy)
O Education
Full Name of Graduate School: Complete Address of Graduate School:
Type of Degree: Course of Study or Degree Major: Did you graduate? (Yes/No)
What Year?
Full Name of College or University: Complete Address of College or University:
Type of Degree: Course of Study or Degree Major: Did you graduate? (Yes/No)
What Year?
Full Name of High School: Complete Address of High School:
Type of Degree: Course of Study or Degree Major: Did you graduate? (Yes/No)
What Year?
Full Name of School/Agency conducting High School Equivalency Training: Complete Address of School/Agency conducting High School Equivalency Training:
Full Name of High School Equivalency Diploma Issuing Agency: Complete Address of High School Equivalency Diploma Issuing Did you receive your diploma? (Yes/No) Agency:
Full Name of Business/Trade/Technical School: Complete Address of Business/Trade/Technical School:
Type of Degree: Course of Study or Degree Major: Did you graduate? (Yes/No)
Place your initials in the box to the right
P Employment Please provide your complete and accurate full-time and part-time employment record starting with your present or most recent employer.
Full Name of Employer: Describe Work Experience:
Employer’s Street Address:
Employer’s City/State/Zip Code:
Supervisor’s Name and Job Title:
Employer’s Telephone Number:
Your Job Title:
Employed From (Mo./Yr.): Employed To (Mo./Yr.): Full Time Part Time Were you terminated from this position? Yes No Explain:
Base Salary: Overtime Earnings: Bonus Earnings: Reason for Leaving:
Full Name of Employer: Describe Work Experience:
Employer’s Street Address:
Employer’s City/State/Zip Code:
Supervisor’s Name and Job Title:
Employer’s Telephone Number:
Your Job Title:
Employed From (Mo./Yr.): Employed To (Mo./Yr.): Full Time Part Time Were you terminated from this position? Yes No Explain:
Base Salary: Overtime Earnings: Bonus Earnings: Reason for Leaving:
Full Name of Employer: Describe Work Experience:
Employer’s Street Address:
Employer’s City/State/Zip Code:
Supervisor’s Name and Job Title:
Employer’s Telephone Number:
Your Job Title:
Employed From (Mo./Yr.): Employed To (Mo./Yr.): Full Time Part Time Were you terminated from this position? Yes No Explain:
Base Salary: Overtime Earnings: Bonus Earnings: Reason for Leaving:
Place your initials in the box to the right
P Employment (continued)
Full Name of Employer: Describe Work Experience:
Employer’s Street Address:
Employer’s City/State/Zip Code:
Supervisor’s Name and Job Title:
Employer’s Telephone Number:
Your Job Title:
Employed From (Mo./Yr.): Employed To (Mo./Yr.): Full Time Part Time Were you terminated from this position? Yes No Explain:
Base Salary: Overtime Earnings: Bonus Earnings: Reason for Leaving:
Full Name of Employer: Describe Work Experience:
Employer’s Street Address:
Employer’s City/State/Zip Code:
Supervisor’s Name and Job Title:
Employer’s Telephone Number:
Your Job Title:
Employed From (Mo./Yr.): Employed To (Mo./Yr.): Full Time Part Time Were you terminated from this position? Yes No Explain:
Base Salary: Overtime Earnings: Bonus Earnings: Reason for Leaving:
Q References List references, not relatives, who have personal knowledge of your training, experience and capability.
Full Name and Job Title of Reference: Reference employed by:
Full Address of Reference: Daytime Telephone Number of Reference:
Full Name and Job Title of Reference: Reference employed by:
Full Address of Reference: Daytime Telephone Number of Reference:
Full Name and Job Title of Reference: Reference employed by:
Full Address of Reference: Daytime Telephone Number of Reference:
Place your initials in the box to the right
Licenses Other than a driver license, specify those licenses that are relevant to the position that you are applying for.
R
Special Skills and Abilities List special skills and abilities such as computer skills, foreign language proficiency, etc.
S
Membership in Professional or Civic Organizations Exclude those which may disclose your race, color, religion or national origin.
T
U Additional Information List any additional information that you feel would help us in evaluating your application.
Place your initials in the box to the right
V Background Verification/Field Investigation/Release of Information
NOTIFICATION UNDER THE PERSONAL PRIVACY PROTECTION LAW
As a prospective, newly-hired or promoted employee of MTA Bridges and Tunnels (legal name, Triborough Bridge and Tunnel Authority), you are required to accurately complete, swear to, and submit this form. The information you supply is subject to written, telephone, and personal verification. You are required to sign an authorization for MTA Bridges and Tunnels to obtain certain information.
The information is requested pursuant to the general powers of MTA Bridges and Tunnels and will principally be used to evaluate your background and qualifications with respect to the position for which you have applied. The information about you which is obtained in connection with your background verification will be maintained by the Human Resources Department of MTA Bridges and Tunnels at 2 Broadway, 22nd Fl. New York, New York 10004 in care of the Director, Human Resources and Training. The information submitted may be disclosed to officers, employees, and contractors of the MTA Bridges and Tunnels, its affiliates, and subsidiaries in connection with the performance of official duties, and to others in connection with the purpose for which the information is collected. Except as disclosure is permitted under New York State Personal Privacy Protection Law (Public Officers Law Article 6-A), the information submitted by you shall be deemed to have been submitted by you in confidence unless you otherwise notify the MTA Bridges and Tunnels. Contact the Director, Human Resources & Training for further information as to such notification.
A false statement or intentional omission of any material fact on this application may cause you to be disqualified, dismissed even following your employment, and may lead to prosecution.
I authorize MTA Bridges and Tunnels (legal name, Triborough Bridge and Tunnel Authority) and all contractors performing background investigation services for MTA Bridges and Tunnels or any of their agents to procure an investigative consumer report for employment purposes, which may include information about my character, background, general reputation, personal characteristics, credit worthiness, or mode of living and may also include personal interviews with my present and former employers, present and former neighbors, friends, associates, and others acquainted with me. I understand that before adverse action, including the denial of my employment, can be taken against me in whole or in part due to a consumer report, I will be provided with a copy of the report and a written summary of my rights under the Fair Credit Reporting Act. I also understand I may have additional rights under applicable state law.
I authorize all persons, corporations, companies, credit agencies, educational institutions, present and former employers, federal, state and local government agencies, law enforcement agencies, workers’ compensation agencies, criminal, civil and federal courts, and military services (“Information Sources”) to release any information they may have about me to MTA Bridges and Tunnels and all contractors performing background investigation services for MTA Bridges and Tunnels or any of their agents. I release all Information Sources from any liability for releasing such information.
I declare, subject to the penalties of disqualification, dismissal even following my employment, and/or prosecution, that the statements made on this application (including the statements made in any accompanying papers submitted by me) have been examined by me and to the best of my knowledge and belief are true and correct.
Print First Name: Print Last Name:
Applicant’s Signature: Date: