1 of 8 Human Resouces Form #03
PH 6/4/14 HR Notes:
Employment Application
Capital Area Transit System is an Equal Employment Opportunity Employer
Applicant Information
First Name Middle Initial Last Name Social Security Number
Street Address Apt #
City State ZIP Code
Home Phone Cell Phone/Other Contact Email Address
Position
Position Applying For Job Posting Number Date Able to Begin Work Today’s Date How did you learn about this position? (check one)
☐Walk-In ☐Newspaper ☐Internet ☐Employee Referral
Employee Who Encouraged You to Apply Have you previously worked for
CATS? ☐Yes ☐No
If yes, give dates and position
Special Provision - Commercial Driver’s License (CDL)
A valid CDL is a requirement for employment as a Bus Operator or Any Maintenance position. A CDL Class B with a Passenger Endorsement and without an Air Brake Restriction is the minimum licensure required to operate. If you have a license lower than a CDL or have a CDL Class B Permit, you are allowed to apply, but the minimum licensure must be obtained before being allowed to work as a Bus Operator or Maintenance staff.
License # Class State Expiration Date
Endorsements Restrictions
Have you had any accidents where you were at fault with in the last 5 years? ☐Yes ☐No
If yes, give date and location Have you been charged with a DUI or DWI with in the
last 5 years? ☐Yes ☐No
If yes, give date and location *Personal Driver’s License required for Custodians and Groundskeepers*
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PH 6/4/14
Education
Highest Level Completed (mark one):
☐
1
☐2
☐3
☐4
☐5
☐6
☐7
☐8
☐9
☐10
☐11
☐12
☐GED
College:
☐Freshman
☐Sophomore
☐Junior
☐Senior
☐Beyond Undergrad
Schools School Name City, State
Dates Attended Graduation Date Degree/Major Area of Study
High School College or University Graduate or Professional Business or Trade School Other Programs
Other licenses, certifications, or special training
List all computer programs, office equipment, machinery, and tools you can operative efficiently
References
Provide information for persons who have first-hand knowledge of your skills, abilities, and work ethic.
Name Company Relationship Phone Number
Name Company Relationship Phone Number
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PH 6/4/14
Work History
List your work history beginning with your current or last employer. Please include any self-employment, military service, full-time training or school programs, and any extended periods of unemployment.
Position Title Start Date End Date Reason for Leaving
Company Name City State Phone Number
Supervisor’s Name and Title Starting Salary Ending Salary May we contact? ☐Yes ☐No
Brief description of duties Covered by DOT regulations?
☐Yes ☐No
Position Title Start Date End Date Reason for Leaving
Company Name City State Phone Number
Supervisor’s Name and Title Starting Salary Ending Salary May we contact? ☐Yes ☐No
Brief description of duties Covered by DOT regulations?
☐Yes ☐No
Position Title Start Date End Date Reason for Leaving
Company Name City State Phone Number
Supervisor’s Name and Title Starting Salary Ending Salary May we contact? ☐Yes ☐No
Brief description of duties Covered by DOT regulations?
☐Yes ☐No
Position Title Start Date End Date Reason for Leaving
Company Name City State Phone Number
Supervisor’s Name and Title Starting Salary Ending Salary May we contact? ☐Yes ☐No
Brief description of duties Covered by DOT regulations?
4 of 8 Human Resouces Form #03
PH 6/4/14
Background Check Authorization
I hereby authorize Capital Area Transit System (CATS) to
investigate my background and qualifications for purposes of evaluating my qualifications for the position for which I am applying. I understand that CATS 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.
Signature Date
First Name Middle Name Last Name
Other Names, Nicknames, Maiden Name, aliases you may be known by in the past Gender
☐Male ☐Female
Date of Birth City, State/Parish of Birth Social Security Number Other than minor traffic violations, do you
have any criminal convictions? ☐Yes ☐No
If yes, briefly describe conviction, include date and location:
Drug Free Workplace
It is Capital Area Transit System goal to ensure a safe and healthy work environment and to provide a safe transit system for the public Per CATS Drug and Alcohol Policy, any employee who holds a safety sensitive position or an applicant for such position is covered under this policy. CATS requires Alcohol/Drug test for:
Pre-Employment Reasonable Suspicion Return to Work
Random Follow-Up Post-Accident
Return to Duty
DOT-FTA regulated individuals will be tested for the following five (5) drugs:
Amphetamines Cocaine (including crack) Marijuana
Opiates Phencyclidine (PCP)
CATS prohibit the unlawful manufacture, distribution, possession, or use of a control substance and/or alcohol in the workplace. Any employee found in violation of the CATS Drug and Alcohol Policy or who receives a positive test for alcohol or prohibited drug(s) or who refuses to take a test will be immediately removed from duty and subject to discharge. Applicants who received a positive test or refuse to take a test will not be hired and will not be eligible to reapply for five (5) years for any position with CATS.
Consent to Drug and/or Alcohol Testing
I have applied for employment with Capital Area Transit System. As a condition for my application being considered, I understand and agree to undergo substance screening. I understand that if my test results are positive, I shall not be considered further by Capital Area Transit System for any position. I hereby authorize any physical, laboratory, hospital or medical professional retained by Capital Area Transit System for screening, and I release Capital Area Transit System and any person affiliated with Capital Area Transit System and any such institution or person conducting the screening, from liability.
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PH 6/4/14
Consent for Reference Check and Employment Verification
I authorize Capital Area Transit System (CATS) to all references and previously employers, unless noted, to
verify information concerning my previous position, dates of employment, salary/hourly wages, rehire status,
reason for separation, character and drug and alcohol safety for the purposes of evaluating employment
eligibility. I authorize the employer named below to release the requested information to CATS for the
purpose of employment. I further waive, release, and discharge the employer listed below from any and all
liability arising from or as result of providing the information requested in this form.
XXX-XX-
Applicant Name
Social Security Number
Date
Applicant Signature
TO BE COMPLETED BY PREVIOUS EMPLOYER
Last Position Held Hire Date End Date Reason for Leaving
Company Name City State Phone Number
Supervisor’s Name and Title Starting Salary Ending Salary Eligible for rehire? ☐Yes ☐No
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PH 6/4/14
Additional Questions
Are you related by blood, marriage, or adoption to any CATS employee? ☐Yes ☐No
If yes, please state who and your relationship
Have you ever tested positive or refused to test with the past two years on any DOT Pre-employment drug or alcohol test administered by a DOT covered employer? ☐Yes ☐No
Can you provide verification of you legal right to work in the United Stated? ☐Yes ☐No
Can you perform the essential functions of the job for which you are applying with or without reasonable
accommodations? ☐Yes ☐No
Voluntary EEO Questions
The following questions are related to recordkeeping and reporting requirements pertaining to Civil Rights laws and regulations. Responses to these questions are voluntary. Refusing to provide information will not affect the screening and application process nor will any information that you provide be held against you. Any responses will remain confidential and only use for enforcement of Civil Rights laws, executive order, regulation and reporting purposes. Gender
☐Male ☐Female
Date of Birth Ethnic Self Identification (check all that apply)
☐Asian ☐Black/African American ☐ Native American/ Alaskan ☐Hawaiian/Pacific Islander ☐Hispanic/Latino ☐White/Caucasian
Veteran Status Branch of Armed Forces you served Discharge Date
Acknowledgement Statement
I attest that the information provided in this employment application is accurate to the best of my knowledge.
I understand that if any information is found to be incorrect, there may be a delay or disqualify consideration
for employment. I understand that if any information is willfully misrepresented, I will be disqualified from this
position and future positions with Capital Area Transit System.
Signature
Date
Please return completed applications to our office in person, by mail or fax
Capital Area Transit System
Attn: Human Resources
2250 Florida Blvd
Baton Rouge, LA 70802
Fax: 225-389-8919
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PH 6/4/14
REQUEST/CONSENT FOR DRUG & ALCOHOL TESTING RECORDS
In compliance with Department of Transportation (DOT) regulations, 49CFR §40.45 Capital Area Transit System (CATS) must obtain information regarding DOT regulated drug and alcohol test records for the last two years.CANDIDATE: Please complete the following:
AUTHORIZATION TO RELEASE INFORMATION
I, _____________________________, authorize my prior & current employer(s) __________________________________
(Candidate’s Name)
(Company Name)
to release and forward the information requested, concerning my drug and alcohol testing records, to Capital Area Transit
System.
I understand that refusal to provide information or written consent regarding these previous test records will result in
disqualification for the safety-sensitive position for which I am applying.
____________________________________________
_____________________________________________
Candidate’s Name –
Please Print
Social Security Number
____________________________________________
_____________________________________________
Candidate’s Si
gnature
Date
THIS SECTION IS TO BE COMPLETED BY PREVIOUS or CURRENT EMPLOYER:
Please complete the following:
Your prompt assistance and cooperation in completing the information below is highly appreciated. Once you answer the
questions, please send the completed document to Fax # 225-389-7717 Phone: 225-389-8920 ext. 318
Safety/Drug & Alcohol Coordinator: _Betina Mitchell______________________________________________________________
In the last two years, since the signature date of this reques
t, has this employee…
1. Participated in a DOT covered Drug & Alcohol testing program?
Yes
No
If YES, please continue answering:
1.
Had a verified positive drug test result?
Yes
No
2.
Refused to be tested (including verified adulterated or substituted drug test results)?
Yes
No
3.Had an alcohol test with a Breath Alcohol concentration of 0.04 or higher?
Yes
No
4.
Violated any other DOT agency and alcohol testing regulations?
Yes
No
5.
Had report from a previous employer of a drug and alcohol rule violation to you?
Yes
No
6.
Had a report of pre-employment positive or refused drug and/or alcohol tests?
Yes
No
If you answered YES to any question other than #1, please provide information regarding Substance Abuse Professional
(SAP) referral, along with any available documentation of the employee’s successful completion of the DOT return
-to-duty
requirements, and all follow-up tests conducted as a result of above violation(s).
Substance Abuse Professional: _________________________________________ Phone: _____________________________
NameAddress: __________________________________________________________________________________________________
Information Provided By: ______________________________________________________ Date: _________________________
Name of Employer
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PH 6/4/14
CANDIDATE DISCLOSURE OF INFORMATION
In addition to Capital Area Transit System internal reviews, Department of Transportation (DOT) and Federal Transit Administration (FTA) regulations 49 CFR Parts 40 and 655, require all DOT federally regulated employers to obtain the drug and alcohol testing records of candidates to positions that include the performance of safety-sensitive duties.A candidate who refuses to authorize the release of this information will not be considered for a safety-sensitive job.
Please answer the following questions:
Have you ever worked for Capital Area Transit System or its predecessor agencies? Yes No
If so, Year___________________ Badge #___________________________
Have you ever worked for a CATS contractor? Yes No
If so, Name _______________________________Year_________________ Badge #_______________________
Current Driver’s License Class:
C
(Non-commercial) _____________
A/B
(Commercial Driver)_____________
Have your previous jobs included commercial or passenger driving? ______________
Did your previous jobs require that you submit for DOT drug & alcohol testing? Yes No
