EMPLOYMENT CENTER INSTRUCTIONS

PLEASE ARRIVE PROMPTLY AT YOUR DESIGNATED TIME IN

BUSINESS CASUAL ATTIRE IS REQUIRED. No Light colored, Distressed or Ripped Jeans, Shorts, Jogging pants/Active wear, Graphic tees, Undershirts, Flip-flops, Tank tops, Halter tops, Leggings, etc. You will be sent home if you are not in business casual attire.

YOU SHOULD BRING THE FOLLOWING ITEMS (A-K) IF APPLICABLE:

A. ONE ORIGINAL DOCUMENT FROM EACH OF THE TWO GROUPS BELOW:

GROUP#1 GROUP #2 * U.S. BIRTH CERIFICATE * VALID DRIVERS’ LICENSE * PUBLIC ASSISTANCE ID * VALID U.S PASSPORT * VALID NON-DRIVERS ID * EMPLOYMENT ID RESIDENT ALIEN CARD

B. ORIGINAL SOCIAL SECURITY CARD

C. THE ENCLOSED LETTER (You must bring your letter with you) D. COMPLETED PRE-EMPLOYMENT APPLICATION FORM (You must read all instructions. Incomplete applications will not be accepted.)

● You must include any UNEMPLOYMENT time when filling out the application. • DO NOT USE WHITEOUT OR CORRECTION TAPE • You must PRINT the COMPLETED PRE-EMPLOYMENT APPLICATION AND BRING TO YOUR APPOINTMENT • You must make a copy of the application and keep for your records.

E. DRIVERS’ LICENSE-VALID NEW YORK STATE

If you have or had an out of state Drivers’ License within the last three years you must bring an abstract/ driver’s record with you. This document cannot be more than 30 days old. (See Job Description for further information of position with drivers’ license requirements.)

F. BALL POINT PEN (BLUE INK ONLY).

G. HIGH SCHOOL DIPLOMA OR G.E.D (IF REQUIRED). H. IF YOU SERVED IN THE MILITARY, BRING IN DD214 (DISCHARGE PAPER). I. IF YOU CLAIMED DISABILITY CREDITS, BRING IN THE DISABILITY LETTER FROM THE VETERANS

ADMINISTRATION. J. IF YOU CLAIMED LEGACY CREDITS, BRING IN 9/11 LEGACY CREDIT LETTER FROM EITHER THE FDNY OR

NYPD.

K. PLEASE BRING A LIGHT LUNCH/SNACK WITH YOU. (THIS CAN BE AN ALL-DAY PROCESS)

Depending upon the title for which you are being considered, a medical assessment may be required. This medical may require for the following:

Vision Testing. If corrective lenses are necessary, bring to the exam. (If you applied for Conductor or Train Operator and wear contact lenses, glasses are also required.)

Hearing test. If hearing aids are used, bring to exam. Documentation of all medications currently being used.

(If currently on medication, take as prescribed on day of examination.)

Please note that this can be an ALL DAY process. Please prepare to be here all day. FOR FURTHER INFORMATION, PLEASE CALL (347) 643-7413.

MONDAY-FRIDAY (9:00-5:00) (Rev 7/29/2019)

PRE-EMPLOYMENT APPLICATIONBACKGROUND VERIFICATION QUESTIONNAIRE

Last Name First MI Title of Position

Home Address, P.O. Box, Number and Street (Apt. No.)

Social Security Number (List other numbers used.)

City and State Zip Code

Home Telephone

G E N E R A L I N F O R M A T I O N

Please print information in ink. If additional space is needed, attach a separate sheet of paper.BE SURE ALL QUESTIONS ARE ANSWERED COMPLETELY.

E M P L O Y M E N T I N F O R M A T I O N

Yes No If No, enter type of visa and/or alien registration number:

Yes No

Are you a United States Citizen?

Are you legally eligible to work in the United States?(Proof of eligibility documentation will be required at the time of hire as required by law.)

Page 1

Mo/Yr Mo/Yr

Supervisor/Telephone:Work HoursPer Week:

Start with your present job and work back to the time you left High School including unemployment time. Do not omit any jobs or required information. If you have more jobs than space permits, request additional Employment Information page(s) to list them. Use an employment section for each time period you were unemployed. Where placed by a temporary employment agency or union, specify the name, address and telephone number of both the temporary employment agency or union and the work placements. Indicate those jobs in which you were self-employed by printing "Self-Employed" and the telephone number next to "Supervisor/Telephone". Include any previous NYC Transit, MaBSTOA, SIRTOA, MTA HQ, MTA Bus Company, Long Island Rail Road, Metro-North, Bridges and Tunnel or Capital Construction employment you may have had at ANYTIME.

Supervisor/Telephone:Work HoursPer Week:

Mo/Yr Mo/Yr

Supervisor/Telephone:Work HoursPer Week:

Mo/Yr Mo/Yr

List other names used, i.e. maiden name, nickname, assumed name.

List your residence(s) in reverse chronological order most recent first for the past 10 years. From Mo/Yr To Mo/Yr

Dates From To

Employer's Full Name, Address and Zip Code(include department name if applicable) Title of Position Reason For Leaving

Present

Page 2 E M P L O Y M E N T I N F O R M A T I O N (continued)

Supervisor/Telephone:Work HoursPer Week:

Supervisor/Telephone:Work HoursPer Week:

Supervisor/Telephone:Work HoursPer Week:

Supervisor/Telephone:Work HoursPer Week:

Supervisor/Telephone:Work HoursPer Week:

Supervisor/Telephone:Work HoursPer Week:

Supervisor/Telephone:Work HoursPer Week:

Supervisor/Telephone:Work HoursPer Week:

Supervisor/Telephone:Work HoursPer Week:

Mo/Yr Mo/Yr

Mo/Yr Mo/Yr

Mo/Yr Mo/Yr

Mo/Yr Mo/Yr

Mo/Yr Mo/Yr

Mo/Yr Mo/Yr

Mo/Yr Mo/Yr

Mo/Yr Mo/Yr

Mo/Yr Mo/Yr

Dates From To

Employer's Full Name, Address and Zip Code(include department name if applicable) Title of Position Reason For Leaving

Supervisor/Telephone:Work HoursPer Week:

Supervisor/Telephone:Work HoursPer Week:

Supervisor/Telephone:Work HoursPer Week:

Supervisor/Telephone:Work HoursPer Week:

Supervisor/Telephone:Work HoursPer Week:

Supervisor/Telephone:Work HoursPer Week:

Supervisor/Telephone:Work HoursPer Week:

Mo/Yr Mo/Yr

Mo/Yr Mo/Yr

Mo/Yr Mo/Yr

Mo/Yr Mo/Yr

Mo/Yr Mo/Yr

Mo/Yr Mo/Yr

Mo/Yr Mo/Yr

E M P L O Y M E N T I N F O R M A T I O N (continued)

Page 2A

Last Name First MI Social Security Number

Signature Date

Title of Position

Dates From To

Employer's Full Name, Address and Zip Code(include department name if applicable) Title of Position Reason For Leaving

Federal and or State law prohibits discrimination in hiring and employment on the basis of race, color, religion, national original, sex age or marital status.No question on this application is intended to secure information used for such discrimination.

Human Resources\eForms (REV. 07/19)

A P P L I C A N T ' S S T A T E M E N T

Major

# of Credits

Yes

No

Yes

No

Yes

No

E D U C A T I O N I N F O R M A T I O N

Major

# of Credits

Major

# of Credits

M I L I T A R Y I N F O R M A T I O NYes No

Yes No

2. What was your Military Occupational Specialty (MOS)?

Dishonorable discharges are not an absolute bar to employment. Other factors will effect a final decision. If hired, your response may be verified.

P R O F E S S I O N A L O R T R A D E L I C E N S E I N F O R M A T I O N

(If the answer is yes, specify type of license or certification, action taken, from/to date and the reason below.)

Page 3

I declare, under penalties of penal law, that I have completed all pages of the Pre-employment Application/BackgroundVerification Questionnaire and that the statements contained therein are to the best of my knowledge and belief, true and correctand that I have not knowingly and willingly made a false statement or given information which I know to be false in connectiontherewith.

Yes

No

Major

# of Credits

Yes No4. Are you claiming U.S. Armed Forces Veterans Credits for this position?

Signature Date

List high school, college, graduate school and special training. Write the full name of diploma/degree (for example, High SchoolDiploma or Bachelor of Arts).

1. Have you served in the U.S. Armed Forces?If Yes, indicate entry and separation dates.

3. Were you dishonorably discharged?If Yes, explain:

1. List state professional or trade licenses issued, number and expiration date

2. Was any license/certification held by you ever suspended, restricted or revoked, or have you ever been censured ordisciplined by any licensing or certifying organization? Yes No

Name and Address Graduate Degree/Diploma Course

Last Name First MI Social Security Number

P R I O R E M P L O Y M E N T T E R M I N A T I O N (S)Page 5

Signature Date

Title of Position

Were you ever terminated, dismissed, removed (not laid off) or disqualified for a position, including public employment? If you answer Yes, give full details including dates. Yes No

NOTIFICATION / AUTHORIZATION / RELEASE OF INFORMATION

I, authorize release of any(Print Name)

MTA New York City TransitEmployment Operations

180 Livingston StreetBrooklyn, New York 11201

REV. 08/17

records or documents that includes, but is not limited to, employment records, personaldocuments, education documents and documents relating to my termination ofemployment to the New York City Transit Authority, Manhattan and Bronx Surface TransitOperating Authority, MTA Bus Company, Staten Island Rapid Transit Operating Authorityand/or MTA Business Service Center (hereinafter referred to as the Authority), theirofficers, agents, employees and servants for the preparation of a report or investigationrelating thereto.

The authorization for release of information includes, but is not limited to, matters ofopinion relating to my character, ability, reputation and past performance. I authorize allpersons, schools, companies, corporations and law enforcement agencies to releasesuch information without restriction or qualification to the Authority, and any of its officers,agents, employees and servants. I voluntarily waive all recourse and release the abovesources and firms, including the Authority, from liability for complying with thisauthorization. I understand that any offer of employment from the Authority will becontingent upon the results of a number of factors including this backgroundinvestigation.

Signature Date

DISCLOSURE AND AUTHORIZATION FOR RELEASE OF MOTOR VEHICLE RECORD (MVR) INFORMATION

I authorize New York City Transit Authority, Manhattan and Bronx Surface Transit Operating Authority, MTA Bus Company, SIRTOA and its designated agents and representatives to obtain and review my motor vehicle record (MVR) information. I voluntarily supply the information necessary to obtain driver license information from any state that I have been licensed to drive a motor vehicle and release all parties involved from liability for doing so. This authorization shall be valid in original, fax or copy form and shall serve as an ongoing authorization to procure MVR information on an ongoing basis during my employment so long as I remain in a title or assignment requiring a driver’s license.

Fill out the information below so your MVR information can be obtained. (Please type or print information legibly.)

Full Name: __________________________________________________________________________ Last Name First Name

Driver License #:_________________________________________________________

License Class: ______________________________ Issuing State: ______________

___________________________________________________ _____________________ Signature Date

DMV Authorization. Doc February 2011

PRINT NAME AS IT APPEARS ON LICENSE SOCIAL SECURITY NO. TITLE OF NEW POSITION

PERMANENTPROMOTION

PROVISIONALPROMOTION

TEMPORARYPROMOTION

PERMANENTAPPOINTMENT

PROVISIONALAPPOINTMENT

NON-COMPETITIVE

ADDRESS, CITY, STATE, ZIP CODE

MOTOR VEHICLE LICENSE INFORMATION

If Yes, note here

Indicate the number of years you have possessed a license without any break prior to the present date

Was license denied, suspended or revoked? Yes No From ToReason

(If none, write "None." If you have nothing pending, write "None and Nothing Pending.")

Motorist I.D. Number State

For further violations (use other side)

Has applicant been involved in an accident during the past three years which resulted in property damage or physical injury? If yes,please explain.

Explain

a)

c)

d)

f) Yes No

Yes No

b) Location of accident

e) Number of individuals confined to a hospital as a result of the accident

Date Signature

DECLARATION (TO BE COMPLETED BY APPLICANT)

Human Resources\eForms (REV. 08/16)

This appointment is subject to the receipt of a New York State Drivers License, Class B at the end of the training period.

Class Expiration Date

License Restrictions: Yes No

FOR BUS OPERATOR TITLE ONLY. In order to be appointed to the title of Bus Operator you must present evidence that you possessa license valid in the State of New York. You must have had a Drivers License for at least THREE (3) YEARS immediately prior toappointment.

FAILURE TO PROVE WITH DOCUMENTS TO THE SATISFACTION OF THE PERSONNEL DEPARTMENT THAT YOU POSSESSEDSUCH LICENSE FOR THE REQUIRED PERIOD OF TIME WILL RESULT IN YOUR DISQUALIFICATION AND THE TERMINATIONOF YOUR SERVICE.

DATE OF BIRTH (M/D/Y)

"I declare under penalties of the penal law, that I prepared this form and that the statements contained herein are to the best of my knowledgeand belief true and correct and that I have not knowingly and willfully made a false statement or given information which I know to be false inconnection herewith."

Was police report filed

Number of individuals injured

Extent of property damage

Date of accident

SERIOUS MOVING VIOLATIONS OR ACCIDENT RECORD MAY DISQUALIFY. THEREFORE, LIST BELOW ALL PENDING VIOLATIONS FOR TRAFFIC.All applicants will be thoroughly investigated. Therefore, any omission or willful misstatement will be cause for disqualification for employment..NOTE: For out of state (any state other than New York) license holder or any out of state violations, attach abstract of operating record.

DATE OFVIOLATION OFFENSE DISPOSITION

AND FINECOURT AND LOCATION

New York City Transit

Date: __________________

Print Social Name: _____________________________________ Security ___________________________

I am a retiree from ________________________New York City/ New York State agency. Name of agency

I am not a retiree from a New York City/ New York State agency.

X_________________________ Candidate’s Signature

I am a Veteran Yes No

I have claimed Veterans Credits before with a government agency within New York City or New York State.

____________________________ Agency Name

I have not claimed Veterans Credit before with a government agency within New York City or New York State.

X_________________________ Candidate’s Signature

6/28/13

Bus Company Staten Island Railway

New York City Transit Bus Company Staten Island Railway ________________________ (Date) Name ___________________________________________ Social Security No. During the past two years, did you work for any period of time or applied Yes No to work for a DOT regulated employer? Did you test positive or refused to test on any DOT pre-employment drug Yes No or alcohol test administered by a DOT covered employer for which you did not get the job? X _______________________________________ __________________ Applicant Signature Date If answered yes to any of the above questions, on the next page, please CLEARLY print the name and address of the employer and sign the information release statement.

THIS FORM IS FOR MTA NEW YORK CITY TRANSIT, MTA BUS AND MTA STATEN ISLAND RAILWAY.

OFFICIAL USE ONLY

Page 1 of 2

New York City Transit Bus Company Staten Island Railway

Release of Information Form – 49 CFR Part 40 Drug and Alcohol Testing

________________________ (Date)

Social Security No. Name _______________________________________

Please CLEARLY print the name and address of the employer and sign the information release statement.

USE ONE FORM FOR EACH DOT EMPLOYER DURING THE PREVIOUS TWO YEARS, IF APPLICABLE.

Employer Name ________________________________________ ________________________________________ (Telephone #)

Employer Address ________________________________________

________________________________________ ________________________________________ Designated Employer Representative (if known)

I hereby grant the DOT regulated employer identified above, permission to release drug and alcohol testing information related to DOT covered drug and alcohol testing program to MTA New York City Transit for any part of the two year period to the date of this letter. This includes questions one through five as stated below. I understand that continued employment is contingent on the findings of the USDOT employer verification and further understand that I will not be hired to perform safety sensitive functions if I refuse to sign below. I understand any misrepresentation may result in a denial of my employment application, or, if currently an employee, appropriate disciplinary action.

X ___________________________________________ _____________________ Applicant Signature Date

Dear Employer:

It is NYC Transit's understanding that you are a DOT regulated employer and that the above applicant has/had been employed or has applied to be employed by you during the past two years.

MTA New York City Transit for employment in a position covered by the U.S Department of Transportation as safety sensitive. Safety sensitive functions include, but are not limited to: operation of revenue service vehicles including when not in revenue service; operation of non-revenue service vehicles that require drivers to hold CDLs; dispatch or control revenue service vehicles; maintain revenue service vehicles or equipment used in revenue service except for contractors to section 18 transit agencies; and provide security and carry firearm. In accordance with the provisions of federal law, 49 CFR Part 40, Section 40.25, we are requesting that you answer the questions below regarding DOT regulated drug and alcohol testing covering any period during two years prior to the date of this letter. Above please find a signed release granting consent for you to provide the information by the above applicant.

1. Did the employee have alcohol tests with a result of 0.04 or higher? YES NO

2. Did the employee have verified positive drug tests? YES NO

3. Did the employee refuse to be tested? YES NO

4. Did the employee have violations of DOT agency drug and alcohol testing regulations? YES NO

5. Did a previous employer report a drug and alcohol rule violation to you? YES NO

6. If you answered "yes" to any of the above items, did the employee complete the return-to-duty process? YES NO N/A

X _______________________________________________ _____________________ Employer Signature Date

Print Name _____________________________________ Title _____________________________ Contact Number ________________________

Please mail or fax the information back to: MTA New York City Transit

Occupational Health Services, Drug Reporting Unit 180 Livingston Street, Room 4026

Brooklyn, NY 11201 Fax (347)643-8186

Thank you for your anticipated cooperation in this matter. Revised 06/13/2016

Page 2 of 2

Corporate Compliance: Ethics Form-001 Updated January 2017 Page 1 of 2

All Agency Outside Activity Approval Request HR-EMP-304

Section 1 - Information and Instructions (Please Contact Your Supervisor Prior to Completing this Form)

1) Any employee desiring employment outside the MTA and any of its Agencies (“MTA”) should complete this form and obtain approval before engaging in any outside activity. If you are an Employee in a policy-making position, you must complete this form and possibly the New York Joint Commission (“JCOPE”) on Public Ethics Outside Activity Form to request permission to: (a) hold elected or appointed public office, (b) serve as a director or officer of a profit-making corporation or institution, (c) serve as a director or officer of a not for profit-making corporation or institution, that qualifies as a Prohibited Source, or (d) engage in an outside activity from which you expect to receive more than $5,000 in annual compensation. See MTA Code of Ethics and your Agency Dual/Outside Employment Policies for additional information. 2) Newly hired employees who wish to continue other outside activities/employment should file this form prior to their appointment date. If this request is subsequently denied, you must terminate your outside activity/employment within two (2) business days of receipt of determination or in such other time frame or manner as is requested by the employee and approved by your Agency Ethics Officer. 3) Prior to completing this form, you must discuss this matter with your supervisor and Ethics Officer who will advise you on how to complete this form, and the information you must provide about the outside activity. Please attach supporting documentation (e.g., job description, details on outside activity). Employees in Public-Safety Positions or Safety-Sensitive Titles must consult their Agency Dual/Outside Employment Policies for additional requirements. 4) Any approval is based upon your current position and outside activity/employment. If there is any change in either, please contact your Supervisor or Agency Ethics Officer to determine whether a new request is required. You may be required to certify annually that there has been no change in either your outside activity or your position with the MTA. 5) If approved, a copy of the completed form will be sent by your Agency to the Business Service Center for inclusion in your personnel file.

Section 2 - Employee Information

Employee Name Policy Maker Yes No Date of Request

Employee Title BSC ID Agency ID or Pass# (If Applicable)

Agency Department

Telephone Number E-mail Address

Current Work Schedule Current Hours Worked

Section 3 – Category of Request (Check all that Apply) *Must complete JCOPE Outside Activity Report

Outside Activity Annual Compensation under $5,000

Outside Activity Annual Compensation over $5,000* Est. Annual Amount: $ _________

Corporate Officer or Director* Non Profit Officer or Director

Public Office* Elected Position*

Section 4 – Nature of Outside Activity

Name of Organization Your Proposed Title/Position

Organization’s Address City State Zip Code

Nature and type of business, profession, or other outside activity

Does the organization conduct business with any of the following (If Yes, contact your Agency Ethics Officer) : MTA or its Agencies;

MTA Contractor or Subcontractor; Any MTA or MTA Agency Employee.

Detailed description of services to be performed by you (Attached Separate Sheet if Needed)

Work Schedule Work Hours Proposed Start Date

Section 5 - Acknowledgement

I acknowledge that the outside activity described above will not be conducted on MTA or Agency time or using MTA or Agency resources, and that in no way will it interfere with the performance of my responsibilities at the MTA or Agency. This activity would not, to the best of my knowledge and belief, constitute a violation of Public Officers Law §73-a, or §74 or the MTA Code of Ethics, which I have reviewed.

Signature of Employee Date

Corporate Compliance: Ethics Form-001 Updated January 2017 Page 2 of 2

All Agency Outside Activity Approval Request HR-EMP-304

Section 6 –Approval-Supervisor I recommend that the above-stated outside activity be approved, having determined that this outside activity would not interfere with the Employee’s discharge of his or her duties to the MTA.

Signature

Date

Print Name:

Section 7 –Approval-Department Head I approve the above-stated outside activity based upon the information provided, having determined that this outside activity is appropriate, considering MTA Code of Ethics, applicable policies, procedures, and other rules or regulations governing employee conduct which may apply.

Signature

Date

Print Name:

Section 8 –Approval-Legal/Ethics Officer (Required for Policy Makers and All MTAHQ Employees) I approve the above-stated outside activity, having determined that this outside activity is appropriate, considering MTA Code of Ethics, this agency’s applicable policies, procedures, and other rules or regulations governing employee conduct which may apply.

Signature

Date

Print Name:

Section 9 – Approval-Chief Compliance Officer or Designee (Required for Agency Presidents and all MTAHQ Employees) I approve the above-stated outside activity based upon the information provided, having determined that this outside activity is appropriate, considering MTA Code of Ethics, applicable policies, procedures, and other rules or regulations governing employee conduct which may apply.

Signature

Date

Print Name: DDR#