<p> Tri County Transportation, Inc. Health Ride Plus</p><p>406 Magnolia Street PO Box 1007 Northern Cambria, PA 15714 Phone (814) 948-6537 Fax (814) 948-4821 APPLICATION FOR EMPLOYMENT</p><p>In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability.</p><p>Date of application: ______</p><p>Position Applied for ______</p><p>Name ______Phone ______Last First Middle</p><p>Email address ______</p><p>Social Security No. ______Birth date: ______(required for Commercial Drivers)</p><p>Current Address ______Street City ______State Zip Code How Long?</p><p>Previous Addresses</p><p>Street City State Zip Code How Long?</p><p>Do you have a legal right to work in the United States? ______</p><p>Have you worked for this company before? ______Where? ______Dates? ______</p><p>Reason for leaving ______</p><p>Are you now employed? ______If not, how long since leaving last employment? ______</p><p>Who referred you? ______Rate of pay expected ______</p><p>Is there any reason you might be unable to perform the functions of the job for which you have applied?</p><p>______</p><p>If yes, explain ______All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle. </p><p>(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)</p><p>Employer Date From To Name Mo. Yr. Mo. Yr. Address Position Held City State Zip Salary/Wage Contact Person Phone number Reason for Leaving </p><p>Employer Date From To Name Mo. Yr. Mo. Yr. Address Position Held City State Zip Salary/Wage Contact Person Phone number Reason for Leaving </p><p>Employer Date From To Name Mo. Yr. Mo. Yr. Address Position Held City State Zip Salary/Wage Contact Person Phone number Reason for Leaving </p><p>* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.</p><p>Accident record for past 3 years or more (Attach sheet if more space is needed). If none, write NONE.</p><p>Dates Nature of Accident Fatalities Injuries (Head-on, Rear-end, Upset, etc) </p><p>Last Accident </p><p>Next Previous </p><p>Next Previous </p><p>Traffic convictions and forfeitures for the past 3 years (other than parking violations) If none, write NONE.</p><p>Location Date Charge Penalty</p><p>EDUCATION</p><p>Are you a High School Graduate? yes no </p><p>Did you attend College? If yes, how many years? ______</p><p>Last School attended ______Name City State</p><p>Experience and Qualifications - Driver Driver Licenses State License No. Type Expiration date</p><p>Have you ever been denied a license, permit or privilege to operate a motor vehicle? yes no </p><p>Has any license, permit or privilege ever been suspended or revoked? yes no </p><p>IF THE ANSWER TO EITHER IS YES, ATTACH STATEMENT GIVING DETAILS</p><p>Driving Experience</p><p>Class of Equipment Type of Equipment Dates Approx. no. of miles (Van, Tank, Flat, Etc.) From To (Total) Motor Coach - School Bus Straight Truck Tractor and Semi Trailer Tractor - two Trailers Other </p><p>List any training, awards, experience or qualifications for the position that you are applying for</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______To be read and signed by Applicant</p><p>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.</p><p>I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.</p><p>In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.</p><p>______Date Applicant’s Signature Tri County Transportation, Inc. Health Ride Plus</p><p>404 Magnolia Street PO Box 1007 Northern Cambria, PA 15714 Phone (814) 948-6537 Fax (814) 948-4821</p><p>FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT</p><p>In accordance with the provisions of Section 604 (b)(2)(A); 606 and 615 of the Fair Credit Reporting Act, effective September 30, 1997, you are being informed that reports verifying you previous employment, previous drug and alcohol test results, and your driving record my be obtained on you for employment purposes.</p><p>Note: In accordance with DOT regulations for appropriate drivers these reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carriers Safety Regulations.</p><p>I also understand that my employer will periodically review my Motor Vehicle Record to determine continued eligibility to drive a company vehicle. </p><p>This authorization is valid as long as I am an employee and may only be rescinded in writing.</p><p>Candidate and/or Employee Acknowledgment</p><p>______Print Full Name as it appears on Drivers License Date </p><p>______Signature Social Security Number </p><p>______Birth Date Driver License Number State Expiration AUTHORIZATION FOR CRIMINAL RECORD CHECK</p><p>(Please read and sign this form in the space provided below. Your written authorization is necessary for completion of the application process.)</p><p>I, ______, hereby authorize Tri County Transportation¸ Inc./Health Ride Plus to do a Request for Criminal Record Check through the Pennsylvania State Police for purposes of evaluating whether I am qualified for the position for which I am applying. I understand that Tri County Transportation¸ Inc. will utilize an outside firm or firms to assist it in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company's choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for employment will not be processed further.</p><p>______Signature of Employee Date</p><p>______Employee's Name - Printed</p>