employment application external - november 2014.pdf

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INSTRUCTIONS FOR COMPLETING

EMPLOYMENT APPLICATION

1. Complete all sections of the Employment Application thoroughly and accurately.

2. You must include all your employment history for the past ten years (if applicable) or

above. If you need more space to complete your employment history, use the

Supplemental Application form that has been included in your application package.

The supplemental application must be used to complete the additional employment

information.

3. If you have a conviction, violation or infraction including traffic related matters,

please provide an explanation of the conviction, violation or infraction on the sheet

that has been provided in the package.

IN ANSWERING THIS QUESTION, DO NOT DISCLOSE ANY CONVICTION

THAT (i) IS A SEALED CONVICTION OR (ii) THAT IS CLASSIFIED AS A

YOUTHFUL OFFENDER ADJUDICATION.

4. Failure to follow these instructions will result in a delay in processing your

application.

5. After your interview, if you are selected to continue in the process, the next step will

be a background investigation of the information that you have provided on your

Employment Application.

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Employment Office

MTA LONG ISLAND RAIL ROAD

EMPLOYMENT APPLICATION

LAST NAME (PLEASE PRINT) FIRST NAME (M) DATE

Company Policy prohibits discrimination on the basis of race, sex, sexual orientation, color, age, national origin, creed or disability.

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EMPLOYMENT APPLICATION Failure to answer every question could result in a delay of your application.

PERSONAL INFORMATION

LAST NAME (please print)

FIRST

MIDDLE

SS# (Last 4 Digits Only)

HOME (STREET) ADDRESS

CITY OR TOWN

STATE

ZIP CODE

MAILING ADDRESS, if different

HOME TELEPHONE NO.

PAGER NO. CELL PHONE NO. FAX NO. E-MAIL ADDRESS

EDUCATIONAL INFORMATION

DO YOU HAVE A:

HIGH SCHOOL DIPLOMA G.E.D. NONE

OTHER TRAINING (including military)

WHERE DID YOU OBTAIN YOU H.S. DIPLOMA OR G.E.D.?

School: Address: City: State:

COLLEGE (list all attended)

MAJOR SUBJECT DID YOU RECEIVE A:

DEGREE CERTIFICATE

NEITHER

TYPE: IF NONE, # CREDITS COMPLETED:

ADDRESS



DEGREE CERTIFICATE

NEITHER


ADDRESS



DEGREE CERTIFICATE

NEITHER


ADDRESS

ARE YOU PRESENTLY ATTENDING SCHOOL PART-TIME?

YES NO

ARE YOU PLANNING TO ATTEND SCHOOL?

YES NO

IF YES, EXPLAIN

BUSINESS AND PROFESSIONAL MEMBERSHIPS, LICENSES AND/OR CERTIFICATES RELATED TO THIS POSITION

NAME OF ORGANIZATION DATES CITY STATE OFFICES HELD, IF ANY

NAME OF ORGANIZATION DATES CITY STATE OFFICES HELD, IF ANY


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EMPLOYMENT INFORMATION (List all employers for the last 10 years, starting with most recent. Give full addresses including non-US employers – use Supplemental Forms, if necessary).

NAME OF EMPLOYER

REASON FOR LEAVING EMPLOYMENT DATES(Month/Year) FROM: TO:

ADDRESS

SUPERVISOR’S NAME/TITLE LAST SALARY

CITY STATE ZIP

COMPANY TELEPHONE NO. YOUR TITLE

HR ADDRESS (If Different)

HR TELEPHONE NO. HR NAME/TITLE

DESCRIBE DUTIES AND RESPONSIBILITIES:

NAME OF EMPLOYER


ADDRESS


CITY STATE ZIP





NAME OF EMPLOYER


ADDRESS


CITY STATE ZIP





NAME OF EMPLOYER


ADDRESS


CITY STATE ZIP






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HAVE YOU EVER FILLED OUT AN APPLICATION FOR YES EMPLOYMENT WITH THE LONG ISLAND RAIL ROAD? NO

HAVE YOU EVER BEEN EMPLOYED BY YES THE LONG ISLAND RAIL ROAD? NO

IF YES, WHAT POSITION?

WHAT WAS THE RESULT? YEAR IF YES, WHAT POSITION? REASON FOR LEAVING? YEAR

DO YOU HAVE A VALID DRIVER’S LICENSE? STATE: YES NO

HAVE YOU EVER BEEN EMPLOYED BY YES ANY OTHER RAIL ROAD OR MTA AGENCY? NO

DO YOU HAVE ANY OTHER STATE OR FEDERAL YES LICENSES (INCLUDING TRADE OR OCCUPATION)? IF YES, INDICATE TYPE: NO

IF YES, WHAT RAIL ROAD OR AGENCY? POSITION YEAR

SUPPLEMENTARY INFORMATION HAVE YOU EVER SERVED IN THE U.S. ARMED FORCES? BRANCH OF SERVICE RANK AT DISCHARGE

YES NO IF YES, PLESE INDICATE YOUR STATUS BELOW: I AM CURRENTLY ACTIVE DUTY/RESERVES IN THE U.S. ARMED

FORCES. I AM A VETERAN WITH HONORABLE DISCHARGE AND A DD-214. I AM A VETERAN WITH OTHER THAN HONORABLE DISCHARGE.

DATE OF SERVICE (MONTH/YEAR)

FROM TO

ARE YOU OR HAVE YOU EVER BEEN A MEMBER OF A PUBLICLY-FUNDED PENSION SYSTEM IN NYC OR NYS? YES NO IF YES, PLEASE PROVIDE NAME OF SYSTEM AND INDICATE MEMBERSHIP TIER IF APPLICABLE:

IF YOU ANSWERED YES, ARE YOU CURRENTLY RECEIVING RETIREMENT BENEFITS FROM THIS PENSION PLAN? YES NO

HAVE YOU EVER BEEN CONVICTED OF A CRIME, VIOLATION YES NO OR INFRACTION? (Including Traffic Convictions) IN ANSWERING THIS QUESTION, DO NOT DISCLOSE ANY CONVICTION THAT (i) IS A SEALED CONVICTION OR (ii) THAT IS CLASSIFIED AS A YOUTHFUL OFFENDER ADJUDICATION.

DO YOU HAVE ANY ACTIONS PENDING AGAINST YOU? YES NO IF YOU ANSWERED YES TO EITHER OR BOTH OF THESE QUESTIONS, PLEASE USE THE ATTACHED CONVICTION FORM (S) TO EXPLAIN THE CIRUMSTANCES. A SEPARATE CONVICTION FORM MUST BE USED FOR EACH OCCURRENCE.

ARE YOU LEGALLY ELIGIBLE TO WORK IN THIS COUNTRY? YES NO

WILL YOU NOW OR IN THE FUTURE REQUIRE “SPONSORSHIP FOR AN IMMIGRATION RELATED EMPLOYMENT BENEFIT?” YES NO

ANY OBJECTIONS TO WORKING NIGHTS, WEEKENDS OR HOLIDAYS? YES NO

HAVE YOU EVER BEEN TERMINATED FROM A JOB FOR A CAUSE? YES NO

IF YES, EXPLAIN

IF SELECTED, HOW MUCH NOTICE DO YOU NEED TO GIVE CURRENT EMPLOYER?

MINIMUM SALARY REQUIREMENT:

I certify that the information on this application and any attachments are, to the best of my knowledge and belief, complete and accurate and that I have not knowingly withheld or falsified any pertinent facts or circumstances. I hereby authorize MTA Long Island Rail Road or its authorized agents to investigate my background and verify information provided. I certify that I will advise LIRR of any subsequent changes to this Employment Application. I understand that any omission or misrepresentation of material fact in this application may result in rejection of this application or dismissal. I further understand that an employment offer by MTA Long Island Rail Road maybe contingent on a medical and/or physical examination and the results of the background investigation. Signature________________________________________________________________Date_________

FOR HR USE ONLY INTERVIEWED BY: DATE:

COMMENTS:


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GENERAL APPLICATION FOR EMPLOYMENT (Supplemental Form) Your application will not be considered unless every question is answered.

PERSONAL INFORMATION LAST NAME (please print)

FIRST MIDDLE SS# (Last 4 Digits Only)

ADDITIONAL EMPLOYMENT INFORMATION 5. NAME OF EMPLOYER


ADDRESS


CITY STATE ZIP


HR ADDRESS (If Different) HR TELEPHONE NO. HR NAME/TITLE

6. NAME OF EMPLOYER


ADDRESS


CITY STATE ZIP




7. NAME OF EMPLOYER


ADDRESS


CITY STATE ZIP


HR ADDRESS (If Different) HR TELPHONE NO. HR NAME/TITLE

FOR HR USE ONLY I certify that the information on this application and any attachments are, to the best of my knowledge and belief, complete and accurate and that I have not knowingly withheld or falsified any pertinent facts or circumstances. I hereby authorize MTA Long Island Rail Road or its authorized agents to investigate my background and verify information provided. I certify that I will advise LIRR of any subsequent changes to this Employment Application. I understand that any omission or misrepresentation of material fact in this application may result in rejection of this application or dismissal. I further understand that an employment offer by MTA Long Island Rail Road maybe contingent on a medical and/or physical examination and the results of the background investigation. Signature_______________________________________Date__________________

INTERVIEWED BY:

DATE:

COMMENTS:


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GENERAL APPLICATION FOR EMPLOYMENT

CONVICTION FORM (A)

NAME:___________________________________DATE:_____________

SOCIAL SECURITY NUMBER: ____________(LAST 4 DIGITS ONLY)

Please complete the following information thoroughly, specifically and accurately, as this

information will be included in a background investigation.

The term “offense” includes felonies, misdemeanors, violations, and traffic infractions. A plea of

guilty is a conviction even if you were never imprisoned, were placed on probation, only paid a

fine, were conditionally or unconditionally discharged or received a Certificate of Relief from

Disabilities.

A conviction record or pending charges will not be an automatic bar to employment. Your

application will be considered in its entirety. However, any false statement of fact or

omission thereof, regarding convictions or pending charges may disqualify you from

employment.

In answering the following questions, DO NOT DISCLOSE any conviction that (i) is a

SEALED CONVICTION OR (ii) that is classified as a YOUTHFUL OFFENDER

ADJUDICATION.

(A) Have you ever been convicted of an offense anywhere? Yes No

(B) If yes, list each conviction on a Supplemental Form A – Explanation of Conviction.

(C) Have you been charged with or accused of an offense that is currently pending

against you? Yes No

(D) If yes, list each pending charge on a Supplemental Form B – Explanation of Pending

Charge.

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Supplemental Form A- Explanation of Conviction If you answered “yes” to the question on page 5 of LIRR’s General Application for Employment

– “Have you ever been convicted of a crime, violation or infraction? (Including Traffic

Convictions)” – provide the information requested below. Use a separate form for each

conviction.

In answering this question, DO NOT DISCLOSE ANY CONVICTION THAT (i) IS A SEALED

CONVICTION OR (ii) THAT IS CLASSIFIED AS A YOUTHFUL OFFENDER

ADJUDICATION.

DATE OF INCIDENT: ____/____/____COUNTY___________________STATE__________

NAME & LOCATION OF COURT:

_____________________________________________________________________________________

_______________________________________________________________________

EXPLAIN THE INCIDENT IN YOUR OWN WORDS:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________

DATE OF SENTENCE: ____/____/____

SENTENCE:_________________________________________________________________________

_____________________________________________________________________________________

_________________________________________________________________

Print Name: ___________________________________________________________________

Signature: ______________________________________________ Date:_________________

Social Security No. (Last 4 digits Only)________________________

Reviewed by

HR Representative:_______________________Date:______________________________

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Supplemental Form B- Explanation of Pending Charge

If you answered, “yes” to the question on page 5 of LIRR’s General Application for Employment

– “Do you have any actions pending against you?” – provide the information requested below.

Use a separate form for each pending charge.

DATE OF INCIDENT: ____/____/_____COUNTY_______________STATE__________

NAME & LOCATION OF COURT:

_____________________________________________________________________________________

_______________________________________________________________________

EXPLAIN THE CHARGE IN YOUR OWN WORDS:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Print Name: _________________________________________________________________________

Signature: ________________________________________Date:_________________

Social Security No. (Last 4 digits Only)________________________

Reviewed by

HR Representative:_______________________Date:______________________________

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Attachment A-Policy 2103-Avoidance of Nepotism

APPLICANT RELATIVE DISCLOSURE FORM It is the policy of the MTA Long Island Rail Road (LIRR) to make employment decisions based solely on

merit. In addition, the employment or placement of family members that would result in a conflict of interest

is prohibited.

The MTA Code of Ethics defines a “family member” as (i) an LIRR employee’s spouse, domestic partner,

child or sibling; (ii) a person who is a direct descendant (or the spouse of a direct descendant) of a

grandparent of the LIRR employee or a grandparent of the LIRR employee’s spouse or domestic partner; or

(iii) any person living in the same household as an LIRR employee.

Are you aware if any of your family members have applied for employment with the MTA Long Island

Rail Road (LIRR) within the last twelve (12) months? Yes No (Check one)

To the best of your knowledge, are any of your family members present or former employees of the

MTA Long Island Rail Road (LIRR) or present or former MTA Long Island Rail Road (LIRR) union officials?

Yes No

If you answered “yes” to either of the above questions, state with respect to each such Relative:

Name _________________________________________________________________

Relationship _________________________________________________________________

Position _________________________________________________________________

Department _________________________________________________________________

Name _________________________________________________________________

Relationship _________________________________________________________________

Position _________________________________________________________________

Department _________________________________________________________________

Name _________________________________________________________________

Relationship _________________________________________________________________

Position _________________________________________________________________

Department _________________________________________________________________

This statement becomes part of the employment application and is subject to the same provisions

regarding false and misleading information.

I,___________________________, certify that the information given above is true and that I have not

knowingly withheld any facts. It is understood that any false statements will be grounds for rejection

of my application or dismissal.

Signature:__________________________________ Dated:___________________________

HR Representative:__________________________ Dated:___________________________

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REFERRAL SOURCE

Please indicate how you were referred to the MTA Long Island Rail Road.

Please check appropriate box:

Newspaper Advertisement (Name of Newspaper)_____________________

Other Advertisement__________________________________________

LIRR Employee______________________________________________

Website_____________________________________________________

Job Fair_____________________________________________________

Job Posting__________________________________________________

Unsolicited__________________________________________________

College Placement____________________________________________

Professional Organization______________________________________

State Employment Agency______________________________________

“Keeping Track” Pamphlet______________________________________

Other_______________________________________________________

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APPLICANT DATA FLOW QUESTIONNAIRE

To The Candidate: Completion of this questionnaire is voluntary and optional.

The MTA Long Island Rail Road is an Equal Opportunity Employer (M/F/D). The

information requested is to assist us with our record keeping. The information will

kept confidential and will not be used to make a decision about your employment.

Gender: Male Female

Ethnicity: Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central

American, or other Spanish culture or origin, regardless of race.

Race: White (not Hispanic or Latino) – A person having origins in any of the original peoples of

Europe, the Middle East, or North Africa.

Black or African American – A person (not Hispanic or Latino) having origins in any of the

Black racial groups in Africa.

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, and Vietnam

Native Hawaiian or Other Pacific Islander – A person (not Hispanic or Latino) having

origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

American Indian or Alaska 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

maintain tribal affiliation or community attachment.

Other – All persons who identify with two (2) or more of the above five (5) races.

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Safety Sensitive Positions

Employees who are newly hired or promoted to Safety Sensitive positions must provide

written consent for the MTA Long Island Railroad (“LIRR”) to obtain the following

information from Department of Transportation (DOT) regulated employers who have

employed the employee during any period two years before the date of the employee’s

application or transfer. The following information will be requested:

1. Alcohol tests with a result of 0.04 or higher alcohol concentration;

2. Verified positive drug tests;

3. Refusals to be tested (including verified adulterated or substituted drug test

results);

4. Other violations of DOT agency drug and alcohol testing regulations;

5. With respect to an employee who violated a DOT drug and alcohol regulation,

documentation of the employee’s successful completion of DOT return to duty

requirements (including follow-up tests). If the previous employer does not have

information about the return to duty process (e.g. an employer who did not hire an

employee who tested positive on a pre-employment test) the employee must

provide that information.

Attached is a Supplemental Application for Safety Sensitive Positions. Please complete the

application and print and sign your name where indicated.

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SUPPLEMENTAL APPLICATION FOR SAFETY-SENSITIVE POSITIONS

Please answer the following questions, print and sign your name on the space provided:

1. Have you been employed in a Department of Transportation (DOT) regulated position over the last

two (2) years? Yes No

If you answered “Yes”, please list the Company name(s) and addresses where you performed

DOT regulated work in the last two (2) years.

A.________________________________________________________________

B.________________________________________________________________

2. In the past two (2) years have you been denied employment for a DOT regulated safety-sensitive

position because you tested positive on the pre-employment drug or alcohol test? If you answer “Yes”,

please provide details pertaining to the positive test result. Yes No

____________________________________________________________________

3. In the past two (2) years, have you ever refused to undergo any pre-employment drug or alcohol test

administered by an employer, and were denied employment, for a DOT regulated safety-sensitive work

for which you were applying? If you answer “Yes”, please provide details pertaining to the refusal to

test. Yes No

____________________________________________________________________

4. Have you ever violated a DOT drug and alcohol regulation? If you answer “Yes”, indicate the employer

you were working for and when this violation occurred. Yes No

_________________________________________________________________________

5. If you answered “Yes” to question #2, #3, and/or #4, you must provide documentation of your

successful completion of DOT return to duty requirements, including follow-up drug and alcohol tests.

As a prospective, newly hired or promoted employee of the MTA-Long Island Rail Road, you are required to

sign an authorization for the LIRR to obtain information from DOT regulated employers who have employed

you during the two (2) years before the date of your application or transfer.

I, (print name)________________________________________________________________,

authorize the MTA Long Island Rail Road to obtain information from DOT regulated employers who have

employed me during the last two (2) years before the date of my application or transfer. I understand that if I

do not provide written consent, I will not be able to perform safety-sensitive functions.

Signature_______________________________________Date:___________________________

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Employment Office

DISCLOSURE STATEMENT - ALL APPLICANTS

Have you ever been disciplined in your present or past positions? Yes No

You may verify this statement with:

Supervisor’s Name: ____________________________________________________________

Telephone Number:____________________________________________________________

Company Name: ____________________________________________________________

Company Address: ____________________________________________________________

If the answer to above question is yes, please provide information regarding all such disciplinary action as

indicated below. Please include the date and the details of the incident that led to the disciplinary action and the

final outcome of the disciplinary process.

Complete a separate disclosure statement for each employer.

Date of the incident: ___/____/___

Provide details of the incident:_______________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Disciplinary Action taken:_______________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Date of the incident: ___/____/___

Provide details of the incident:___________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Disciplinary Action taken:_______________________________________________________________________

_______________________________________________________________________________________________

I certify that the information on this disclosure statement is to the best of my knowledge and belief, complete and

accurate and that I have not knowingly withheld or falsified any pertinent fact or circumstances. I hereby

authorize MTA Long Island Rail Road to verify this information.

I understand that any omission or misrepresentation of material fact in this disclosure will result in rejection of

my Employment Application or dismissal.

_________________________________ ________________________ _____________

Print Name Signature Date

_______________________________ _______________________

(Human Resources Representative) Date

Authorization-Release (3405)

Revised: 11/11/08

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MTA Long Island Rail Road

REFERENCES

NAME:___________________________ DATE:____________

Please provide two (2) professional references in addition to those already included on your Employment

Application, as follows:

(1)

Name: Job Title:

Company Telephone No.:

Street

City

State Zip Code

(2)

Name: Job Title:

Company Telephone No.:

Street

City

State Zip Code

Signature:__________________________________ Date: __________________________

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AUTHORIZATION/RELEASE Current/Prior Employees of MTA Agencies Only

To be completed only by applicants who are currently employed or were previously employed at an

MTA Agency – New York City Transit, Metro-North Railroad, Bridges and Tunnels, Business Service Center, Capital

Construction, Headquarters or Long Island Rail Road.

Please provide the MTA Agency name and address and the name and telephone number of

your current or former supervisor at an MTA Agency.

Agency Name: Job Title:

Supervisor: Telephone No.:

Company:

Street

City

State Zip Code

Regarding my application for employment, please furnish The Long Island Rail Road

Company with attendance (3 years), discipline, service records and performance appraisals (if applicable) relating to

my employment with your agency at your earliest convenience.

Records should preferably be faxed to (718) 558 – 6896 or (718) 523 –6888, or mailed to:

The Long Island Rail Road Company

Employment Office, Mail Code 2902 ( Att:________________)

Jamaica Station

Jamaica, New York 11435

I,___________________________, certify that the information given above is true and that I have

not knowingly withheld any facts. It is understood that any false statements will be grounds

for rejection of my application or dismissal.

___________________________________

Print Name

___________________________________ _______________________________

Signature Date

__________________________________ _______________________________

(Human Resources Representative) Date

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Consent to Request Consumer Report & Investigative Consumer Report Information

Applicant's First Name or Initial Last Name

I understand that MTA-LIRR (MTA –Long Island Rail Road) will use Sterling Infosystems Inc., 1 State Street, New York, NY 10004, (877) 424-2457 to obtain a consumer report and/or investigative consumer report (“Report”) for employment purposes. I also understand that if hired, to the extent permitted by law, LONG ISAND RAIL ROAD may obtain further Reports throughout my employment for an employment purpose from Sterling.

I understand Sterling Infosystems Inc.’s (“STERLING”) investigation may include obtaining information regarding my credit background, bankruptcies, lawsuits, judgments, paid tax liens, unlawful detainer actions, failure to pay spousal or child support, accounts placed for collection, character, general reputation, personal characteristics and standard of living, driving record and criminal record, subject to any limitations imposed by applicable federal and state law. I understand such information may be obtained through direct or indirect contact with former employers, schools, financial institutions, landlords and public agencies or other persons who may have such knowledge. If an investigative consumer report is being requested, I understand such information may be obtained through any means, including but not limited to personal interviews with my acquaintances and/or associates or with others whom I am acquainted.

The nature and scope of the investigation sought is indicated by the selected services below: (Employer Use Only)

Criminal Background Check

Education Verification

Sex Offender Search

SSN Trace/Address Locator

Employment Verification

OFAC/Terrorist Watch List

Motor Vehicle Report

Personal Reference Verification

Fraud & Abuse Control Info System (FACIS®)

Employment Credit Report

Professional License/Certification

Office of Inspector General Sanctions (OIG)

Other Please List:

I acknowledge receipt of the attached summary of my rights under the Fair Credit Reporting Act and, as required by law, any related state summary of rights (collectively “Summaries of Rights”).

This consent will not affect my ability to question or dispute the accuracy of any information contained in a Report. I understand if LONG ISAND RAIL ROAD makes a conditional decision to disqualify me based all or in part on my Report, I will be provided with a copy of the Report and another copy of the Summaries of Rights, and if I disagree with the accuracy of the purported disqualifying information in the Report, I must notify LONG ISAND RAIL ROAD within five business days of my receipt of the Report that I am challenging the accuracy of such information with STERLING.

I hereby consent to this investigation and authorize LONG ISAND RAIL ROAD to procure a Report on my background.

In order to verify my identity for the purposes of Report preparation, I am voluntarily releasing my date of birth, social security number and the other information and fully understand that all employment decisions are based on legitimate non-discriminatory reasons.

The name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries regarding the investigative consumer report is:

Sterling Infosystems, Inc. | 1 State Street, 24th Floor, New York, NY 10004 | 877-424-2457 | or | 5750 West Oaks Boulevard, Ste. 100 Rocklin, CA 95765 | 800-943-2589 |or | 6111 Oak Tree Boulevard, Independence, OH 44131 |800-853-3228

California, Maine, Massachusetts, Minnesota, New Jersey & Oklahoma Applicants Only: I have the right to request

a copy of any Report obtained by LONG ISAND RAIL ROAD from STERLING by checking the box. (Check only if you wish to receive a copy)

California, Colorado, Connecticut, Maryland, Oregon, Vermont and Washington State Applicants Only (AS

APPLICABLE): I further understand that LONG ISAND RAIL ROAD will not obtain information about my credit history, credit worthiness, credit standing, or credit capacity unless: (i) the information is required by law; (ii) I am seeking employment with a

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financial institution (California, Colorado, Connecticut and Vermont only – in California the financial institution must be subject to Sections 6801-6809 of the U.S. Code and in Vermont it must be a financial institution as defined in 8 V.S.A.§ 11101(32) or a credit union as defined in 8 V.S.A. § 30101(5)); (iii) I am seeking employment with a financial institution that accepts deposits that are insured by a federal agency, or an affiliate or subsidiary of the financial institution or a credit union share guaranty corporation that is approved by the Maryland Commissioner of Financial Regulation or an entity or an affiliate of the entity that is registered as an investment advisor with the United States Securities and Exchange Commission (Maryland only); (iv) I am seeking employment in a position which involves access to confidential financial information (Vermont only); (v) I am seeking employment in a position which requires a financial fiduciary responsibility to the employer or a client of the employer, including the authority to issue payments, collect debts, transfer money, or enter into contracts (Vermont only); (vi) the LONG ISLAND RAIL ROAD can demonstrate that the information is a valid and reliable predictor of employee performance in the specific position being sought or held; (vii) I am seeking employment in a position that involves access to an employer’s payroll information (Vermont only); (viii) the information is substantially job related, and the bona fide reasons for using the information are disclosed to me in writing, (complete the question below) (Colorado, Connecticut, Maryland, Oregon and Washington only);(ix) I am seeking employment as a covered law enforcement officer, emergency medical personnel, firefighter police officer, peace officer or other law enforcement position (California, Oregon and Vermont only - in Oregon the police or peace officer position must be sought with a federally insured bank or credit union and in Vermont the law enforcement officer position must be as defined in 20 V.S.A. § 2358, the emergency medical personnel must be as defined in 24 V.S.A. § 2651(6), and the firefighter position must be as defined in 20 V.S.A. § 3151(3)); (x) the LONG ISAND RAIL ROAD reasonably believes I have engaged in specific activity that constitutes a violation of law related to my employment (Connecticut only); (xi) I am seeking a position with the state Department of Justice (California only); (xii) I am seeking a position as an exempt managerial employee (California only); and/or (xiii)) I am seeking employment in a position (other than regular solicitation of credit card applications at a retail establishment) that involves regular access to all of the following personal information of any one person: bank or credit card account information, social security number, and date of birth,, I am seeking employment in a position that requires me to be

a named signatory on the employer’s bank or credit card or otherwise authorized to enter into financial contracts on behalf of the employer, I am seeking employment in a position that involves access to confidential or proprietary information of the LONG ISAND RAIL ROAD or regular access to $10,000 or more in cash (California only).

Bona fide reasons why LONG ISAND RAIL ROAD considers credit information substantially job related (complete if this is the sole basis for obtaining credit information) or in California and Vermont the LONG ISAND RAIL ROAD’S basis for the credit check.

_____________________________________________________________________________________________________

NY Applicants Only: I also acknowledge that I have received the attached copy of Article 23A of New York’s Correction Law. I further understand that I may request a copy of any investigative consumer report by contacting STERLING. I further understand that I will be advised if any further checks are requested and provided the name and address of the consumer reporting agency.

California Applicants and Residents: If I am applying for employment in California or reside in California, I understand I have the right to visually inspect the files concerning me maintained by an investigative consumer reporting agency during normal business hours and upon reasonable notice. The inspection can be done in person, and, if I appear in person and furnish proper identification; I am entitled to a copy of the file for a fee not to exceed the actual costs of duplication. I am entitled to be accompanied by one person of my choosing, who shall furnish reasonable identification. The inspection can also be done via certified mail if I make a written request, with proper identification, for copies to be sent to a specified addressee. I can also request a summary of the information to be provided by telephone if I make a written request, with proper identification for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or directly charged to me. I further understand that the investigative consumer reporting agency shall provide trained personnel to explain to me any of the information furnished to me; I shall receive from the investigative consumer reporting agency a written explanation of any coded information contained in files maintained on me. “Proper identification” as used in this paragraph means information generally deemed sufficient to identify a person, including documents such as a valid driver’s license, social security account number, military identification card and credit cards. I understand that I can access the following website http://sterlinginfosystems.com/privacy to view STERLING’S privacy practices, including information with respect to STERLING’S preparation and processing of investigative consumer reports and guidance as to whether my personal information will be sent outside the United States or its territories. Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

_______________________________________________________________________________ _______________

Signature: Today’s Date:

http://sterlinginfosystems.com/privacy

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For Office Use Only – Group ID (optional)

For Office Use Only – User ID (optional)

For Office Use Only – Location / Store # (optional)

F I R S T M I D D L E

First Name Middle Name or Initial

L A S T

Last Name Date of Birth (MMDDYYYY)

Other Names Known By Male Female

S O C I A L T E L E P H O N E

Social Security Number Primary Telephone Number (no dashes)

S T R E E T A P T #

Current Address Apt # #yrs at this address *Must include 10 years of residence.

C I T Y

City State Zip Code

S T R E E T A P T #

Previous Address Apt # #yrs at this address *Must include 10 years of residence.

If necessary continue on back.

C I T Y

City State Zip Code

D L #

Driver’s License Number (no dashes) License State

E M A I L

Email Address

Signature Today’s Date (MMDDYYYY)

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DISCLOSURE AND AUTHORIZATION FOR RELEASE OF

MOTOR VEHICLE RECORD (MVR) INFORMATION

I authorize my employer (or prospective employer) and its designated agents and representatives, including but not limited

to the company's insurance agent(s) and/or legal representative 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. I have the right, upon

written request, to a complete an accurate disclosure of the nature and scope of the report and a copy of my Consumer's

Rights under the Fair Credit Reporting Act. 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, membership or

contract period.

FILL OUT THE INFORMATION BELOW SO YOUR MVR

INFORMATION CAN BE OBTAINED

Full Name: Date of Birth:

(Type or Print Name Legibly)

Address:

City, State, Zip Code:

Driver License #:

License Class: Issuing State:

Have you ever held a driver license in any other state other than the above-mentioned issuing state?

YES NO

If YES, list all state(s)

In the past 5 years have you ever been convicted of a traffic offense (not including parking tickets) in any other state other than

the above-mentioned issuing state? YES NO

If YES, list all state(s)

Employee / Prospective Employee Signature Date

ATTACH A PHOTOCOPY OF DRIVER LICENSE (BOTH SIDES) TO THIS SIGNED FORM

(Revised 4/09)

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FAIR CREDIT REPORTING ACT DISCLOSURE AND

AUTHORIZATION FORM

By this document, The Long Island Rail Road Company (LIRR) discloses to you that an investigative

consumer report may be obtained for employment purposes as part of the pre-employment background

investigation, and by your signature below, you authorize the LIRR to obtain such a report. If you are

hired, this authorization shall remain on file and shall serve as an ongoing authorization for the LIRR to

procure investigative consumer reports at any time during your employment. An investigative consumer

report is a report prepared by a consumer reporting agency that may contain information bearing on your

character, general reputation, educational background, criminal history, driving record, personal

characteristics, or mode of living. Such information may be obtained through personal interviews with

your business associates, financial sources, neighbors, friends or others. You have the right to make a

written request, within a reasonable time, for complete disclosure of additional information concerning the

nature and scope of this investigation. Your signature below signifies receipt of the foregoing disclosure

and authorizes the LIRR to obtain the above-described investigative consumer reports.

Print Name: _________________________________________________________________

Signature: ________________________________________________________________

Date: ______/______/______

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Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20006.

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 www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20006.

You must be told information in your file has been used against you. Anyone who uses a credit report, another type of consumer report, to deny your application for credit, insurance, or employment – or 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:

o A person has taken adverse action against you because of information in your credit report;

o You are the victim of identity theft and place a fraud alert in your file; o Your file contains inaccurate information as a result of fraud; o You are on public assistance; o You are unemployed but expect to apply for employment within 60 days.

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 www.consumerfinance.gov/learnmore 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 www.consumerfinance.gov/learnmore for an explanation of dispute procedures.

http://www.consumerfinance.gov/learnmore




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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 www.consumerfinance.gov/learnmore.

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 1-888-5-OPTOUT (1-888-567-8688).

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 www.consumerfinance.gov/learnmore.

You may have additional rights under Article 25 of the NY State General Business Law. For more information, contact the NYS Attorney General or the NYS Department of State’s Division of Consumer Protection. For more information about your federal rights, contact:

TYPE OF BUSINESS: CONTACT:

1a. Banks, savings associations and credit unions with total assets of over $10 billion and their affiliates. 1b. Such affiliates that are not banks, saving associations, or credit unions also should list, in addition to the Bureau:

a. Bureau of Consumer Financial Protection 1700 G Street NW Washington, DC 2006

b. Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580 (877) 382-4357



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2. To the extent not included in item 1 above:

a. National banks, federal savings associations and agencies of foreign banks.

b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and insured state branches of foreign banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act.

c. Nonmember Insured Banks, Insured State Branches of Foreign Banks and insured state savings associations.

d. Federal Credit Unions

a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050

b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480

c. FDIC Consumer Response Center

1100 Walnut Street, Box #11 Kansas City, MO 64106

d. National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street Alexandria, VA 22314

3. Air carriers Asst. General Counsel for Aviation Enforcement & Proceedings Department of Transportation 400 Seventh Street SW Washington, DC 20590

4. Creditors Subject to Surface Transportation Board

Office of Proceedings, Surface Transportation Board Department of Transportation 1925 K Street NW Washington, DC 20423

5. Creditors Subject to Packers and Stockyards Act Nearest Packers and Stockyards Administration area supervisor

6. Small Business Investment Companies Associate Deputy Administrator for Capital Access United States Small Business Administration 406 Third Street, SW, 8

th Floor

Washington, DC 20416

7. Brokers and Dealers Securities and Exchange Commission 100 F Street, NE Washington, DC 20549

8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations

Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090

9. Retailers, Finance Companies, and All Other Creditors not Listed Above

FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center-FCRA Washington, DC 20580 (877) 382-4357

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NEW YORK CORRECTION LAW

ARTICLE 23-A

LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY CONVICTED OF

ONE OR MORE CRIMINAL OFFENSES

Section 750. Definitions

751. Applicability

Unfair discrimination against persons previously convicted of one or more criminal

offenses prohibited.

Factors to be considered concerning a previous criminal conviction; presumption.

Written statement upon denial of licenses or employment.

Enforcement.

§750. Definitions. For the purposes of this article, the following terms shall have the following

meanings:

“Public agency” means the state or any local subdivision thereof, or any state or local

department, agency, board or commission.

“Private employer” means any person, company, corporation, labor organization or association

which employs ten or more persons.

“ Direct relationship” means that the nature of criminal conduct for which the person was

convicted has a direct bearing on his fitness or ability to perform one or more of the duties or

responsibilities necessarily related to the license, opportunity or job in question.

“License” means any certificate, license, permit or grant of permission required by the laws of this

state, its political subdivisions or instrumentalities as a condition for the lawful profession.

Provided, however, that “license” shall not, for the purposes of this article, include any license or

permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other

firearm.

“Employment” means any occupation, vocation or employment, or any form of vocational or

educational training. Provided, however, that “employment” shall not, for the purpose of this

article, include membership in any law enforcement agency.

§751. Applicability. The provisions of this article shall apply to any application by any person

for a license or employment at any public or private employer, who has previously been

convicted of one or more criminal offenses in this state or in any other jurisdiction preceded such

employment or granting of a license, except where a mandatory forfeiture, disability or bar to

employment is imposed by law, and has not been removed by an executive pardon, certification

or relief from disabilities or certificate of good conduct. Nothing in this article shall be

construed to affect any right an employer may have with respect to an intentional

misrepresentation in connection with an application for employment made by a prospective

employee or previously made by a current employee.

§752. Unfair discrimination against persons previously convicted of one or more criminal

offenses prohibited. No application for any license or employment, and no employment or

license held by an individual, to which the provisions of this article are applicable, shall be

denied or acted upon adversely by reason of the individual’s having been previously convicted

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of one or more criminal offenses, or by reason of a finding of lack of “good moral character” when

such finding is based upon the fact that the individual has previously been convicted of one or

more criminal offenses, unless:

There is a direct relationship between one or more of the previous criminal offenses and the

specific license or employment sought or held by the individual; or

the issuance or continuation of the license or the granting or continuation of the employment

would involve an unreasonable risk to property or to the safety or welfare of specific individuals

or the general public.

§ 753. Factors to be considered concerning a previous criminal conviction; presumption.

1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the

public agency or private employer shall consider the following factors:

(a) The public policy of this state, as expressed in this act, to encourage the licensure and

employment of persons previously convicted to one or more criminal offenses.

(b) The specific duties and responsibilities necessarily related to the license or

employment sought or held by the person.

(c) The bearing, if any, the criminal offense or offenses for which the person was

previously convicted will have on his fitness or ability to perform one or more such duties or

responsibilities.

(d) The time which has elapsed since the occurrence of the criminal offense or offenses.

(e) The age of the person at the time of occurrence of the criminal offense or offenses.

(f) The seriousness of the offense or offenses.

(g) Any information produced by the person, or produced on his behalf, in regard to his

rehabilitation and good conduct.

(h) The legitimate interest of the public agency or private employer in protecting

property, and the safety and welfare of specific individuals or the general public.

In making a determination pursuant to section seven hundred fifty-two of this chapter, the public

agency or private employer shall also give consideration to a certificate of relief from disabilities

or a certificate of good conduct issued to the applicant, which certificate shall create a

presumption of rehabilitation in regard to the offense or offenses specified therein.

§ 754. Written statement upon denial of license or employment. At the request of any

person previously convicted of one or more criminal offenses who has been denied a license or

employment, a public agency or private employer shall provide, within thirty days of a request,

a written statement setting forth the reasons for such denial.

§ 755. Enforcement. 1. In relations to actions by public agencies, the provisions of this article

shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil

practice law and rules.

2. In relation to actions by private employers, the provisions of this article shall be enforceable

by the division of human rights pursuant to the powers and procedures set forth in article fifteen

of the executive law, and, concurrently, by the New York City Commission on Human Rights.

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