APPLICATION FOR EMPLOYMENT

Transcription

1 Travis Transit Management, Inc. A subsidiary of RATP DEV Address: ttmi.hr@ratpdev.com APPLICATION FOR EMPLOYMENT BACKGROUND CHECKS TRAVIS TRANSIT MANAGEMENT, INC. RATP DEV May conduct a full background/reference/credit check on candidates for employment. A third party vendor will conduct the background check. PLEASE COMPLETE AND SIGN THE SEPARATE NOTIFICATION FORM DRUG SCREENING TRAVIS TRANSIT MANAGEMENT, INC. RATPDEV is committed to maintaining a DRUG-FREE workplace. All offers of employment are contingent upon successful completion of a pre-employment drug screen. PLEASE COMPLETE AND SIGN THE SEPARATE NOTIFICATION FORM Thank you for considering applying for a position with TRAVIS TRANSIT MANAGEMENT, INC. We appreciate the time you are giving to complete this application form. It is important that you fully and accurately complete this form yourself and indicate the position(s) for which you wish to be considered. Please be very careful completing this application. We use a sophisticated and detailed background and employment screening process which will disclose inaccurate, false, and/or incomplete or omitted information. This application will remain on file for 180 days from the date herein whereupon you should resubmit a new application if you are interested in a position with TRAVIS TRANSIT MANAGEMENT, INC. The following must be filled out completely for your application to be considered [Please Print Clearly or Type] PERSONAL INFORMATION: Name: Last First Middle Have you ever used another name? Yes No List all other names by which you have been known: Position(s) for which you are applying: Present Address: No. Street City State Zip Mailing Address: (if different) No. Street City State Zip Please list the cities and corresponding state you have lived in during the past 7 years: 1) 2) 3) 4) 5) Business Telephone ( ) Home Telephone ( ) Cell Phone ( ) Social Security # Have you ever used another Social Security Number? Yes No Do you have a valid Driver s License? Yes No If so, what state? Driver s License # Have you had a Driver s License: less than one year? 1-2 years? 3 years or more? List all states that you have had a valid Driver s License: List all moving violations and accidents in the past three years: Driver s License classification: C CDL-C CDL-B CDL-A Endorsements: Have you ever been convicted for driving under the influence? Yes No If hired, would you have a reliable means of transportation to and from work? Yes No Page 1 of 5

2 Are you age 21 or older? If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country? (Note: Proof of age and eligibility for employment will be required if you are hired.) Have you ever been terminated or asked to resign from a job? Yes No Please explain: Yes Yes No No Are you available to work: Full Time? Part Time? Seasonal? Shift Work? What days and hours are you available for work? If applying for seasonal work, during what period of time will you be available? From To: Are you available for work on weekends? Yes No Would you be available to work overtime, if necessary? Yes No If hired, on what day can you start work? Have you ever applied to or worked for TRAVIS TRANSIT MANAGEMENT, INC. / RATP DEV before? Yes No If yes, when & where? Do you have any friends or relatives working for TRAVIS TRANSIT MANAGEMENT, INC. / RATP DEV? If yes, name(s) and relationship(s)? Yes No Do you have any commitment to another entity or person that might affect your employment with TRAVIS TRANSIT MANAGEMENT, INC.? Yes No If yes, describe fully. EDUCATION, TRAINING AND EXPERIENCE: No. of Years Degree or Did you School: Name and Address Completed Diploma Graduate? High School Yes No College/University Yes No Vocational/Business Yes No Have you ever served in the United States Military? Yes No Some of our customers/clients may not speak English. Do you speak, write or understand any foreign language(s)? Yes No If yes, which language(s): Do you have any other experience, training, qualifications, or skills which you feel make you especially suited for work at TRAVIS TRANSIT MANAGEMENT, INC.? Yes No Explain: Clerical Skills? Yes No Typing Speed: WPM Ten Key: Yes No Spread Sheet: Yes No Graphics Yes No Word Processing: Yes No DataBase Programs: Yes No Dictaphone: Yes No Accounting Programs: Graphic Programs: Please describe your skills: List any computer Programs with which you are familiar: Page 2 of 5

3 EMPLOYMENT HISTORY: List below all present and past employment for the last ten (10) years, starting with your most recent employer. You must complete this section even if attaching a resume. Note: Attach additional page(s), if necessary. Are you employed now? Yes No If Yes, may we inquire of your present employer? Yes No 1. Name of Employer: Type of Business: Address: No. Street City State Zip Telephone No. ( ) Your Supervisor's Name: Your Position and Duties: Date of Employment: From / / To / / Ending wage Hourly / Monthly Did you operate a Commercial Motor Vehicle on this job? Yes No Was termination voluntary or involuntary? Vol Invol. Exact Reason for Leaving: 2. Name of Employer: Type of Business: Address: No. Street City State Zip Telephone No. ( ) Your Supervisor's Name: Your Position and Duties: Date of Employment: From / / To / / Ending wage Hourly / Monthly Did you operate a Commercial Motor Vehicle on this job? Yes No Was termination voluntary or involuntary? Vol Invol. Exact Reason for Leaving: 3. Name of Employer: Type of Business: Address: No. Street City State Zip Telephone No. ( ) Your Supervisor's Name: Your Position and Duties: Date of Employment: From / / To / / Ending wage Hourly / Monthly Did you operate a Commercial Motor Vehicle on this job? Yes No Was termination voluntary or involuntary? Vol Invol. Exact Reason for Leaving: 4.. Name of Employer: Type of Business: Address: No. Street City State Zip Telephone No. ( ) Your Supervisor's Name: Your Position and Duties: Date of Employment: From / / To / / Ending wage Hourly / Monthly Did you operate a Commercial Motor Vehicle on this job? Yes No Was termination voluntary or involuntary? Vol Invol. Exact Reason for Leaving Page 3 of 5

4 This section intentionally left blank. Have you ever, under your name or another name, been convicted of, or pleaded guilty or nolo contendere to, a felony offense? Yes No If yes, please explain: Have you ever, under your name or another name, been convicted of a crime, which resulted with your being in prison and released from prison or paroled? Yes No If yes, explain each conviction fully, when, where and of what you were convicted and disposition of the case(s): Are you currently awaiting or under indictment for a pending criminal offense? Yes No If yes, state the nature of the crime charged, and when and where trial is pending: Have you ever been dishonorably discharged from any branch of the United States Military? Yes No NOTE: No applicant will be denied employment solely on the grounds that they have been charged, committed or been convicted (or pleaded guilty or nolo contendere) of a criminal offense; or, solely on an affirmative answer above. REFERENCES: List below three persons, not related to you, who have knowledge of your work performance within the last three years. If this does not apply to you, then provide three school or personal references that are not related to you. Name Address Phone Years Known NOTICE: Thank you for completing this application form. If there is a current opening in the position(s) you are seeking and the information in your application suggests you meet minimum qualifications and are among the best qualified candidate for that position, you may be contacted for an interview. If you are interviewed, you will be informed of a final decision once the entire interview process is completed which includes pre-employment drug testing a n d a complete background check conducted by a third party vendor contracted by Travis Transit Management, Inc. The results of the background check may be viewed by Travis Transit Management, Inc., RATP Dev and Capital Metropolitan Transportation Authority in determining employment eligibility. If there is no opening in the position(s) you are seeking, your application will be kept active for 180 days. If you wish to be considered for employment after that time, you must reapply. Thank you for your interest in our company. Please read the following page carefully, print your name, initial, sign, and date. I certify that all of the information provided by me on this Application is true and accurate. Signature: Print Name: Date: TRAVIS TRANSIT MANAGEMENT, INC. / RATP DEV IS AN EQUAL OPPORTUNITY EMPLOYER. IT IS THE POLICY OF THIS COMPANY TO CONSIDER ALL JOB APPLICATIONS ON THE BASIS OF MERIT WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, AGE, NATIONAL ORIGIN, ANCESTRY, MARITAL STATUS, DISABILITY OR ANY OTHER PROTECTED CHARACTERISTIC. Page 4 of 5

5 AUTHORIZATION PLEASE READ THE FOLLOWING CAREFULLY, INITIAL EACH PARAGRAPH, THEN SIGN BELOW PLEASE COMPLETE AND SIGN ANY SEPARATE DOCUMENTS WHICH MAY BE ATTACHED PERSONALLY COMPLETED FORM HONESTLY AND ACCURATELY BY MY SIGNATURE AND INITIALS PLACED BELOW, I PROMISE THAT I HAVE PERSONALLY COMPLETED THIS APPLICATION. I DECLARE THAT THE INFORMATION PROVIDED IN THIS EMPLOYMENT APPLICATION (AND ACCOMPANYING RESUME, IF ANY) IS TRUE AND COMPLETE, AND I UNDERSTAND THAT ANY FALSE INFORMATION OR SIGNIFICANT OMISSIONS MAY DISQUALIFY ME FROM FURTHER CONSIDERATION FOR EMPLOYMENT, AND MAY BE JUSTIFICATION FOR MY DISMISSAL FROM EMPLOYMENT IF DISCOVERED AT A LATER DATE). I UNDERSTAND THAT ANY JOB OFFER WILL BE CONDITIONAL BASED ON THE SATISFACTORY REVIEW OF MY QUALIFICATIONS INCLUDING ANY AND ALL BACKGROUND OR DRUG SCREENING WHICH MAY BE REQUIRED. INITIALS DRUG & ALCOHOL SCREENING IF THE COMPANY MAKES A CONDITIONAL JOB OFFER, I GIVE PERMISSION FOR A PHYSICAL EXAMINATION INCLUDING A PRE -EMPLOYMENT DRUG SCREEN. RESULTS WILL BE HELD IN CONFIDENCE BY TRAVIS TRANSIT MANAGEMENT, INC., RATP DEV, AND CAPITAL METRO, EXCEPT WHERE RELEASE OF SUCH INFORMATION IS REQUIRED BY LAW. INITIALS AUTHORIZATION TO OBTAIN INFORMATION I VOLUNTARILY AND KNOWINGLY AUTHORIZE ANY PAST EMPLOYER; EDUCATIONAL INSTITUTION; LAW ENFORCEMENT AGENCY; STATE, LOCAL, OR FEDERAL AGENCY; MILITARY BRANCH; THE NATIONAL PERSONNEL RECORDS CENTER; PERSONAL REFERENCE; AND/OR OTHER PERSONS; TO GIVE RECORDS OR INFORMATION THEY MAY HAVE CONCERNING MY CRIMINAL HISTORY, MOTOR VEHICLE RECORD, EDUCATIONAL HISTORY, LICENSING, EMPLOYMENT (INCLUDING CHARACTER, EARNINGS HISTORY AND REASONS FOR TERMINATION) OR ANY OTHER INFORMATION REQUESTED BY TRA V I S T R A N S I T M A N A GE M E N T, INC. A N D / O R RATP DEV TO DETERMINE MY ELIGIBILITY FOR EMPLOYMENT. I FURTHER AUTHORIZE TRAVIS TRANSIT MANAGEMENT, INC. AND/OR RATP DEV TO SHARE INFORMATION OBTAINED PURSUANT TO THIS AUTHORIZATION WITH CAPITAL METRO. INITIALS NOTIFICATION & COMPLIANCE WITH RULES I AGREE TO IMMEDIATELY NOTIFY TRAVIS TRANSIT MANAGEMENT, INC.. IF I SHOULD BE CONVICTED OF A CRIME WHILE MY JOB APPLICATION IS PENDING, OR DURING MY EMPLOYMENT IF HIRED. IF I BECOME EMPLOYED, I AGREE TO COMPLY WITH THE RULES, REGULATIONS, POLICIES AND PROCEDURES OF TRAVIS TRANSIT MANAGEMENT, INC.. I FURTHER AGREE TO COMPLY WITH THE RULES ESTABLISHED BY CAPITAL METRO, WHICH ARE BINDING ON TRAVIS TRANSIT MANAGEMENT, INC. AND RATP DEV. INITIALS AGREEMENT FOR AT-WILL EMPLOYMENT I UNDERSTAND AND AGREE THAT I AM APPLYING FOR A POSITION WITH TRAVIS TRANSIT MANAGEMENT, INC. AND AM NOT APPLYING FOR A POSITION WITH RATP DEV. OR CAPITAL METRO. I FURTHER UNDERSTAND THAT NOTHING CONTAINED IN THIS APPLICATION, OR CONVEYED DURING ANY INTERVIEW WHICH MAY BE GRANTED, OR DURING MY EMPLOYMENT IF HIRED, IS INTENDED TO CREATE AN EMPLOYMENT CONTRACT BETWEEN TRAVIS TRANSIT MANAGEMENT, INC. AND ME.. IN ADDITION, I UNDERSTAND AND AGREE THAT IF TRAVIS TRANSIT MANAGEMENT, INC. EMPLOYS ME, MY EMPLOYMENT WILL BE AT-WILL, FOR NO DEFINITE OR DETERMINABLE PERIOD OF TIME, AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES OR SALARY, BE TERMINATED AT ANY TIME, FOR ANY REASON OR FOR NO REASON AT ALL, WITH OR WITHOUT PRIOR NOTICE, AT THE WILL OF TRAVIS TRANSIT MANAGEMENT, INC. OR ME. I UNDERSTAND AND AGREE THAT NO PROMISES OR REPRESENTATIONS CONTRARY TO THE FOREGOING ARE BINDING ON TRAVIS TRANSIT MANAGEMENT, INC., RATP DEV., OR CAPITAL METRO UNLESS MADE IN WRITING AND SIGNED BY ME AND AN AUTHORIZED OFFICER OF TRAVIS TRANSIT MANAGEMENT, INC., RATP DEV, AND/OR CAPITAL METRO PROMISE THAT I HAVE NOT RELIED, AND WILL NOT RELY, ON ANY ORAL OR WRITTEN STATEMENTS TO THE CONTRARY. I UNDERSTAND AND AGREE THAT THIS IS THE ENTIRE AGREEMENT BETWEEN ME AND TRAVIS TRANSIT MANAGEMENT, INC. REGARDING THE TERM OF MY EMPLOYMENT AND REPLACES ANY OTHER ORAL OR WRITTEN AGREEMENT OR UNDERSTANDING. INITIALS I certify that all of the information provided by me on this Application is true and accurate. Further, I have read this Authorization and voluntarily consent to all of its provisions. Signature: Print Name: Date: TRAVIS TRANSIT MANAGEMENT, INC. / RATP DEV. IS AN EQUAL OPPORTUNITY EMPLOYER. IT IS THE POLICY OF THIS COMPANY TO CONSIDER ALL JOB APPLICATIONS ON THE BASIS OF MERIT WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, AGE, NATIONAL ORIGIN, ANCESTRY, MARITAL STATUS, DISABILITY OR ANY OTHER PROTECTED CHARACTERISTIC. Page 5 of 5

6 Prior Employment on Capital Metro Contracts Section 1: Job Applicant Information (Please Print) Name ALL applicants must complete this form Date of Birth Job Applying For Section 2: Employment History with Capital Metro Service Providers Applicants previously employed by a Capital Metro service provider shall be deemed ineligible for rehire by another contract service provider of Capital Metro if their employment is involuntarily separated as a result of a drug and alcohol policy violation, safety or customer service violation, or significant accident history, including those resulting in major property damage or personal injuries. Have you ever worked in the Austin area for any of the following companies? (check all that apply) Capital Metro StarTran ATC/Vancom Capital Area Rural Transportation Syst. (CARTS) Connex DAVE Transportation First Transit Greater Austin Transportation Company (GATC) Herzog Laidlaw Transportation LeFleur Transportation MV Transportation RATP Dev or Travis Transit Management Veolia I have not worked for any of these companies For each company selected above, please provide the following (add additional sheets if necessary): COMPANY POSITION HELD DATE EMPLOYMENT ENDED Applicant Signature Date

7 Fair Credit Reporting Act Disclosure & Authorization As an applicant for employment or a current employee of Travis Transit Management, Inc., you are a consumer with rights under the Fair Credit Reporting Act. When any of the following circumstances exist, Travis Transit Management, Inc. may choose to obtain and use information contained in either a consumer report or an investigative consumer report from a consumer reporting agency about you when: 1) considering your application for employment, 2) making a decision whether to offer you employment, 3) deciding whether to continue your employment (if you are hired), or 4) making other employment-related decisions directly affecting you. For explanation purposes, a consumer reporting agency is a person or business which, for monetary fees, dues, or on a cooperative non-profit basis, regularly assembles or evaluates consumer credit information or other information on consumers for the purpose of furnishing consumer reports to others, such as Travis Transit Management, Inc. A consumer report means any written, oral, or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living, which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing your eligibility for employment purposes. An investigative consumer report means a consumer report or portion thereof in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your neighbors, friends, or associates reported on or with others with whom you are acquainted or who may have knowledge concerning any such items of information. In the event an investigative consumer report is prepared, you may request additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act. AUTHORIZATION By signing below, I, (print name), hereby voluntarily authorize Travis Transit Management, Inc. to obtain either a consumer report or an investigative consumer report about me from a consumerreporting agency and to consider this information when making decisions regarding my employment at Travis Transit Management, Inc. I understand that I have rights under the Fair Credit Reporting Act, including the rights discussed above. Signature: Date:

8 Release of Information Form CFR Part 40 Drug and Alcohol Testing Section I. To be completed by the applicant: Applicant Printed Name: Applicant SS Number: I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer, listed in Section I-B, to the employer listed in Section I-A. This release is in accordance with DOT Regulation 49 CFR Part 40, Section I understand that information to be released in Section II-A by my previous employer, is limited to the following DOT-regulated testing items: 1. Alcohol tests with a result of 0.04 or higher; 2. Verified positive drug tests; 3. Refusals to be tested; 4. Other violations of DOT agency drug and alcohol testing regulations; 5. Information obtained from previous employers of a drug and alcohol rule violation; 6. Documentation, if any, of completion of the return-to-duty process following a rule violation. Applicant Signature: I-A. New Employer Name: Travis Transit Management Address: 2910 E. 5 th Street, Suite I-8 Phone #: _ Austin, TX Designated Employer Representative: Elizabeth Herrera I-B. Previous Employer Name: Address: Fax #: Date: Phone #: Designated Employer Representative (if known): Section II. To be completed by the previous employer: II-A. In the two years prior to the date of the employee s signature (in Section I), for DOT-regulated testing ~ 1. Did the employee have alcohol tests with a result of 0.04 or higher? YES 2. Did the employee have verified positive drug tests? YES 3. Did the employee refuse to be tested? YES 4. Did the employee have other violations of DOT agency drug and alcohol testing regulations? 5. Did a previous employer report a drug and alcohol rule violation to you? YES YES 6. If you answered yes to any of the above items, did the employee complete the return-to-duty process? N/A YES NOTE: If you answered yes to item 5, you must provide the previous employer s report. If you answered yes to item 6, you must also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing record). II-B. Name of person providing information in Section II-A: Title: Phone #: Date: NO NO NO NO NO NO

9 GENERAL RELEASE FORM [IMPORTANT PLEASE TYPE OR PRINT CLEARLY] Revised 3/2012 Employer - Company Name: Address: City: State: Zip Code: ************************************************************************* Subject Legal Name - First: MI: Last: Maiden or Alias Names Used: Social Security Number*: Driver License Number: DOB*: State: Current Street Address: City: State: Zip Code: *Required solely for background screening purposes and will not be used as hiring criteria. NOTICE AND ACKNOWLEDGMENT [IMPORTANT PLEASE READ CAREFULLY BEFORE SIGNING] NOTICE REGARDING BACKGROUND INVESTIGATION Employer may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a consumer report and/or an investigative consumer report which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by Clear Investigative Advantage LLC, 3000 Internet Blvd Suite 610 Frisco, Texas 75034, Tel: or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report. New York applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Employer by contacting the consumer reporting agency identified above directly. ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of consumer reports and/or investigative consumer reports at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Clear Investigative Advantage or another outside organization acting on behalf of Employer, and/or Employer itself. I agree that a facsimile ( fax ) or photographic copy of this Authorization shall be as valid as the original. Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by Employer at no charge whenever you have a right to receive such a copy under California law. Signature: Date: Clear Investigative Advantage, LLC 3000 Internet Blvd Suite 610 Frisco, TX Toll free: 888-CIA-2503 Local: Fax: support@ciaresearch.com

10 Applicant Name: TRAVIS TRANSIT MANAGEMENT, INC. Applicant Social Security number: To be completed by applicant: Pre Employment Questionnaire and Notice 1. Have you ever worked for a DOT Employer? Yes or No (circle one) 2. Have you ever has a positive drug test? Yes or No (circle one) 3. Have you ever refused a drug test? Yes or No (circle one) 4. Have you ever violated any other DOT drug or alcohol testing regulation? Yes or No (circle one) If yes; what was the rule violation? Applicant Signature Date Notice to Applicant: The position you are applying for is subject to the following terms and conditions: Safety Sensitive Position This position is identified as a safety-sensitive position. An employee in this position is required to participate in the Employer s testing program for prohibited substances. Participation in this program is a condition of employment with Travis Transit Management. A safety-sensitive employee is randomly tested for prohibited drug use or alcohol misuse while the employee is performing safety-sensitive functions; just before the employee is to perform safety sensitive functions; or just after the employee has ceased performing such functions. Pre-Employment Screening All applicants are required to pass pre-employment screening which includes physical examination (DOT physical), agility test, and drug screen. Travis Transit Management must receive a negative drug screen result prior to the performance of safety sensitive duties. TTMI Pre-Employment Questionnaire and Notice July

11 DR-1 (Rev. 6/15) TEXAS DPS APPLICATION FOR COPY OF DRIVER RECORD * * MAIL TO: Texas Department of Public Safety, Box , Austin, TX DO NOT MAIL CASH. Mail check or money order payable to: Texas Department of Public Safety Check Type of Record Desired Any questions regarding the information on this form should be directed to the Contact Center at Allow 2-3 weeks for delivery. L 1. Name DOB License Status Latest Address. $ 4.00 L 2. Name DOB License Status 3 Year Record only lists Crashes/Moving Violations. $ 6.00 L 2A. CERTIFIED version of #2. This Record is Not acceptable for a Defensive Driving Course (DDC). $ X 3. Name DOB License Status Record of ALL Crashes/Violations. Furnished to Licensee Only. $ A. CERTIFIED version of #3. Furnished to Licensee Only and is Acceptable for DDC. $ Abstract Record Certified abstract of completed driver record. $ Other: (Original Application, DWLI, etc.) $.00 (If Required) Mail Driver Record To: (Please Print or Type) Requestor s Last Name Requestor s First Name E 5 T H S T Street Address A U S T I Texas Driver License Number N T X City State Zip Code Daytime Telephone Number (include area code) If requesting on behalf of a business, organization, or other entity, please include the following: T R A V I S T R A N S I T M A N A G E M E N T, I N C Name of business, organization, entity, etc. Your Title or Affiliation with above T R A N S P O R T A T I O N Type of business, organization, etc. (i.e., insurance provider, towing company, private investigation, firm, etc.) Information Requested On: M M / D D / Y Y Y Y Texas Driver License Number Date of Birth Suffix (SR., JR., etc.) Last Name First Name Middle Name/Maiden Name Individual s Written Consent For ONE TIME Release to Above Requestor (Requestor, if you do not meet one of the exceptions listed on the back of this form, please be advised that without the written consent of the driver license/id card holder, the record you receive will not include personal information.) I,, hereby certify that I granted access on this one occasion to my Driver License/ID Card record, inclusive of the personal information (name, address, driver identification number, etc.) to. FEE Signature of License / ID Card Holder or Parent / Legal Guardian State and Federal Law Requires Requestors to Agree to the Following: In requesting and using this information, I acknowledge that this disclosure is subject to the federal Driver s Privacy Protection Act (18 U.S.C. Section 2721 et seq.) and Texas Transportation Code Chapter 730. False statements or representations to obtain personal information pertaining to any individual from the DPS could result in the denial to release any driver record information to myself and the entity for which I made the request. Further, I understand that if I receive personal information as a result of this request, it may only be used for the stated purpose and I may only resell or redisclose the information pursuant to Texas Transportation Code Violations of that section may result in a criminal charge with the possibility of a $25,000 fine. I certify that I have read and agree with the above conditions and that the information provided by me in this request is true and correct. If I am requesting this driver record on behalf of an entity, I also certify that I am authorized by that entity to make this request on their behalf. I also acknowledge that failure to abide by the provisions of this agreement and any state and federal privacy law can subject me to both criminal and civil penalties. Date Signature of Requestor Date If you are not requesting a copy of your own record or do not have the written consent of DL/ID holder, you must provide the information requested on the reverse.

12 TRAVIS TRANSIT MANAGEMENT, INC. The information requested is being collected for Equal Employment Opportunity purposes and will not be considered as part of the application for employment. It will be maintained for personnel use only. Please type or print. Position applying for: Name (Last, First, MI) Address Apt. # (if applicable) City, State, Zip Social Security # Date of Birth Gender Male Female Ethnic Origin Driver s License How did you find out about this job? White Black/African American Hispanic/Latino Native Hawaiian/ Pacific Islander Asian American Indian/Alaskan Native 2 or more races Number State Expiration Date TTMI Employee Name: Texas Workforce Commission Newspaper Name: Job Fair College/Univ. Career Day Internet Human Resources Other Specify: Applicant Signature Date 2910 East 5 th Street Suite 1-8 Austin, Texas

13 VOLUNTARY SELF IDENTIFICATION OF PROTECTED VETERAN STATUS PLEASE PRINT Name (Last, First, Middle): Employee Number: An "Active Duty Wartime or Campaign Badge Veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized. Information to identify the campaigns or expeditions that meet this criterion is available at A copy of the list may also be obtained by calling (301) and requesting that a copy of the list be mailed to you. Are you an Active Duty Wartime or Campaign Badge Veteran? 0 Yes 0 No A "Recently Separated Veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service hired during the three-year period beginning on the date of your discharge or release from active duty. Were you separated from the military within the last three years? 0 Yes 0 No If "Yes," date of separation: _ A "Disabled Veteran" is a veteran of the U.S. military who (i) is entitled to compensation (or who but for the receipt of military pay would be entitled to compensation) under laws administered by the Secretary of Veteran Affairs, or (ii) was discharged or released from active duty because of a serviceconnected disability. Are you a Disabled Veteran? 0 Yes 0 No An "Armed Forces Service Medal Veteran" means any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order (61FR 1209). Are you an Armed Forces Service Medal Veteran? 0 Yes 0 No I am a protected veteran, but I choose not to self-identify the classifications to which I belong. I am NOT a protected veteran. If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for your disability. Information concerning your status will be kept confidential except to the extent necessary to provide special accommodations or emergency treatment. Government officials may be informed where required. Your participation is voluntary; failure to respond will not result in adverse treatment.

14 Voluntary Self-Identification of Disability FormCC-305 OMB Control Number Expires 1/31/2017 Page 1of 2 Why are you being asked to complete this form? Because we do business with the government, 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. If you are applying for a job, 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. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier. 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 Deafness Cancer Diabetes Epilepsy Autism Cerebral palsy HIV/AIDS Schizophrenia Muscular dystrophy Bipolar disorder Major depression Multiple sclerosis (MS) Missing limbs or partially missing limbs Post-traumatic stress disorder (PTSD) Obsessive compulsive disorder Impairments requiring the use of a wheelchair Intellectual disability (previously called mental retardation) Please check one of the boxes below: YES, I HAVE A DISABILITY (or previously had a disability) NO, I DON'T HAVE A DISABILITY I DON'T WISH TO ANSWER Your Name Today's Date I

15 Voluntary Self-Identification of Disability Reasonable Accommodation Notice FormCC-305 OMB Control Number 1250-{)()()5 Expires 1/31/2017 Page 2 of2 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 i Section 503 of the Rehabilitation Act of 1973, as amended. 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 PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete. I

16 A Summary of Your Rights Under the Fair Credit Reporting Act The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to more or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment or to take another adverse action against you must tell you, and must give you the name, address, and phone number of the agency that provided the information. You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your file disclosure ). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: a person has taken adverse action against you because of information in your credit report; you are the victim of identity theft and place a fraud alert in your file; your file contains inaccurate information as a result of fraud; you are on public assistance; you are unemployed but expect to apply for employment within 60 day In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See for additional information. You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender. You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See for an explanation of dispute procedures. Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate. Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old. Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access. You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to You may limit prescreened offers of credit and insurance you get based on information in your credit report. Unsolicited prescreened offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court. Identity theft victims and active duty military personnel have additional rights. For more information, visit PLEASE KEEP THIS SUMMARY FOR YOUR RECORDS Please do not attach to application