EMPLOYMENT APPLICATION

1. Each section of this application must be completed in full, even if accompanied by a resume.

2. Application must be completed by applicant. Please print all responses clearly and accurately.

3. Submitting a resume along with this application is strongly recommended.

4. Individuals applying for a driving position must provide a Massachusetts RMV “Unattested Driving Record” obtained within the last 60 days.

5. Please provide valid phone number and an alternate contact method (E-mail or Phone number).

Veterans Transportation is an Equal Opportunity/Affirmative Action Employer

COMPANY APPLYING FOR: ________________________________________Employment Application

APPLICANT INFORMATION

Last Name First M.I. DateStreet

AddressApartment/Unit #

City State ZIPPhon

eE-mail AddressDate

AvailableDesired Salary

Position Applied forHave you ever worked for this company

YES NO If yes when Why did you leave

Can you work all days, including weekends

YES NO Can you work all

NO

Are you at least 18 years of age?

YES NO Have you ever worked

YES NO

Do you have a valid Drivers License? YES NO License Number State Issued

Do you have a Taxi License YES NO Date Issued Expiration Date

Do you have a 7D license YES NO Date Issued Expiration Date

EDUCATION

High School Address

From To Did you graduate?

YES NO

Degree

CollegeFrom To Did you

graduate?YES NO

Degree

Other

From To Did you graduate?

YES NO

Degree

REFERENCES

Please list three professional references.Full Name Relations

hipCompany Name and address

Phone ( )

Full Name RelationshipCompany Name

and addressPhone ( )

Full Name RelationshipCompany Name

and addressPhone ( )

PREVIOUS EMPLOYMENT

Company

Phone ( )

AddressSupervisor

Job Title

Starting Salary

$Ending Salary

$

Responsibilities

From ToReason for Leaving

May we contact your previous supervisor for a reference?

YES NO

Company

Phone ( )

AddressSupervisor

Job Title

Starting Salary

$Ending Salary

$

Responsibilities

From ToReason for Leaving

May we contact your previous supervisor for a reference?

YES NO

Company

Phone ( )

AddressSupervisor

Job Title

Starting Salary

$Ending Salary

$

Responsibilities

From ToReason for Leaving

May we contact your previous supervisor for a reference?

YES NO

MILITARY SERVICE

BranchFrom

To

Rank at Discharge

Type of Discharge

If other than honorable, explain

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature

Date

REQUEST FOR EMPLOYEE INFORMATION

I am currently being considered for employment at_____________________________________

And hereby authorize any of my former employers to release information about my work history in response to the questions below. I release all former employers of any liability to me for doing so.

_____________________________ _____________________________

Name (please print) Date

_____________________________ _________-_________-_________

Signature Social Security Number

_____________________________________________________________________________________

(For Former Employer Use Only)

Date of Employment: From: _______________ To:_______________

Job Title: ___________________________ Duties:________________________________________

Overall Performance: Excellent_____ Good_____ Fair_____ Poor_____

Attendance: Excellent_____ Good_____ Fair_____ Poor_____

Punctuality: Excellent_____ Good_____ Fair_____ Poor_____

Reason for Leaving: ____________________________________________________________________

Eligible for Rehire? Yes_____ No_____

Prepared by: ____________________ ____________________

Name Date

____________________Title

224 Calvary St.

Waltham, MA 02453

781-647-5211 (Fax) 781-891-7804

www.veteranstransportation.com

Drug and Alcohol Testing

Permission Form

I have been made aware that to be considered for employment; I must submit to and pass a pre-employment drug screen.

In case of an accident where you are deemed to be at fault, the company will require you to take an alcohol and drug test immediately.

In case of an accident where you were not deemed to be at fault, the company reserves the right to have you take an alcohol and drug test immediately.

I have received, read and understood the policy surrounding the alcohol and drugs in the workplace, and give my permission for the company to perform drug and alcohol testing according to this policy.

I UNDERSTAND THAT ANY VIOLATION OF THESE POLICIES AND PROCEDURES WILL SUBJECT ME TO POSSIBLE TERMINATION/SUSPENSION OF DUTIES.

Signature: _________________________ Date:_________________________

Name (please print):_________________________

Applicant/Employee Voluntary Self-identification Form

Veteran's transportation Services believes that all persons are entitled to equal employment opportunities and does not discriminate against its applicants or employees because of race, sex, religious creed, national origin, ancestry, sexual orientation, genetic information, disability, veteran status, age, or any other protected group status. Veteran's Transportation Services is subject to certain governmental recordkeeping and reporting requirements for the administration of civil right laws and regulations.

To comply with these laws and regulations, Veteran's Transportation Services invites you to voluntarily self-identify your sex, race, and ethnicity. Submission of this information is strictly voluntary, and refusal to provide it will not subject you to any adverse treatment. The information provided on this form will be kept confidential and

will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal civil rights enforcement. When reported, this data will not identify any specific individual.

Name____________________________________________________ _ Date_______________

(Please print) Last First Middle

Address______________________________________________________________________________

Number and Street

_____________________________________________________________________________________

City, County, State and Zip Code

Signature__________________________________________________ Date_______________

(Please circle one)

Sex: MALE FEMALE

Race & Ethnicity Categories (Please check only one category):

A.______ American Indian or Alaskan Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

B.______ Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, or Vietnam.

C.______ Black or African-American (Not Hispanic or Latino): A person having origins in any of the Black racial groups of Africa.

D.______ Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

E.______ Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

F.______ White (Not Hispanic or Latino): A person having origins in any of the original people of Europe, the Middle East, or North Africa.

G.______ two or more races: All persons who identify with more than one of the above categories.

_______ (check) I am voluntarily self-identifying as a Veteran.

_______ (check) I am voluntarily self-identifying as a Vietnam Veteran.

_______ (check) I am voluntarily self-identifying as a Disabled Veteran.