Champlain Enterprises, Inc. Application for Employment 24950 Country Club Blvd. Suite 300, rth Olmsted, OH 44070 An Equal Opportunity Employer Operated by CommutAir All applications will remain active for one year from the date of application. Thank you for applying for a position with Champlain Enterprises, Inc. In order to assist us in evaluating your qualifications, we have asked for specific personal information in this application. Omission or falsification of information on this application shall be considered sufficient cause for dismissal from or refusal of employment. It is the policy of Champlain Enterprises, Inc. to conform to the laws of the United States and the several states in which it operates and not to discriminate against applicants or employees with regard to their race, age, color, religion, national origin, sex, sexual orientation, military service, disability or any other basis prohibited by law. (Requests for accommodation during the application and interview process should be made in advance and addressed to the Human Resources Department at 440-779-4588 x 307) Please Print Clearly in Ink Last Name First Middle Street Address City State Zip Home Phone: Cell: Email: Social Security Number Position Desired Location Desired Will you work shifts Part-time Minimum Salary Acceptable Will you relocate Overtime Temporary Can you perform the essential functions of the job (see attached job description) for which you are applying with or without reasonable medical accommodations? Are you authorized to work in the U.S? Do you have any aliases? If yes, what are they? Do you have any relatives working for Champlain Enterprises, Inc.? Relationship What airport nearest your home is served by Champlain Enterprises, Inc.? Emergency Person to contact in case of an emergency (Name, Phone Number, Relationship) Employer s Use only --- (Work History, References & Background must accompany application) Department City Starting Date Position Salary Full time or Part time Interviewed By Department Manager (Revised 11/10/11
Military Service Dates of Service Branch Rank Mechanic A & P License Number FCC/First Class Radio License Number Total Months of Experience Line Maintenance Instrument Repair Welding (type) Aircraft Overhaul Avionics Manufacturing Power plant Overhaul Electrical Flight Controls Sheet metal Airframe Other Types of Aircraft and Airframe Engines you have serviced Can you understand and work with blueprints/circuit diagrams? Do you have your own set of tools? Estimated Value Other Special Skills Typing Speed (WPM) Data Entry (SPH) Types of computer software used Types of computer hardware used Other Skills
PLEASE CIRCLE YES OR NO FOR ALL QUESTIONS. IF YOU ANSWER YES TO ANY QUESTIONS EXPLAIN FULLY AT THE BOTTOM OF NEXT PAGE. A. Within the past ten (10) years, have you been convicted, or found not guilty by reason of insanity, of a felony for any of the following criminal acts? 1. Forgery of certificates, false marking of aircraft or other aircraft registration violation 2. Interference with air navigation 3. Improper transportation of a hazardous material 4. Aircraft piracy 5. Interference with flight crewmembers or flight attendants 6. Commission of certain crimes aboard aircraft in flight 7. Carrying a weapon or explosive aboard aircraft 8. Conveying false information and threats 9. Aircraft piracy outside the special aircraft jurisdiction of the United States 10. Lighting violations involving transporting controlled substances 11. Unlawful entry into an aircraft or airport area that serves air carriers of foreign air carriers contrary to establishes security requirements 12. Destruction of an aircraft or aircraft facility 13. Murder 14. Assault with intent to murder 15. Espionage 16. Sedition 17. Kidnapping or hostage taking 18. Treason 19. Rape or aggravated sexual abuse 20. Unlawful possession, use, sale, distribution or manufacture of an explosive weapon 21. Extortion 22. Armed or felony unarmed robbery 23. Distribution or intent to distribute a controlled substance 24. Arson 25. Conspiracy or attempt to commit any of the aforementioned criminal acts 26. A threat 27. Willful destruction of property 28. Importation or manufacture of a controlled substance 29. Burglary 30. Theft 31. Dishonesty, fraud, or misrepresentation 32. Possession or distribution of stolen property 33. Aggravated assault 34. Bribery 35. Illegal possession of a controlled substance punishable by a maximum term of imprisonment of more than 1 year, or any other crime classified as a felony that the Administrator determines indicates a propensity for placing contraband aboard an aircraft in return for money.
B. Have you ever been convicted in any court, of any crime, offense or violation including traffic infractions (i.e. speeding, reckless driving, DWI, DUI, etc.)? Conviction of a crime will not necessarily be a bar to employment. Factors such as age at the time of the offense, type of offense, remoteness of the offense in time and rehabilitation will be taken into account in determining effect on suitability for employment C. Have you ever been involved in or had an aircraft accident, incident or violation? D. Have you ever failed an FAA medical, written, or oral examination, or check ride? E. Has your employment ever been terminated by your employer for any reason? F. Under PRIA, do you have any training or disciplinary concerns we should be aware of? G. Have you ever been asked to leave a training class by an employer? H. Do you now or have you ever used an alias or nickname? I. Have you ever been disqualified from performing safety sensitive duties as a result of violating FAA regulations due to drug or alcohol abuse? J. In the past two years, have you tested positive, or refused to test, on any preemployment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules? If you answered yes, you will be required to provide documents of successful completion of the return to duty process. K. Does your employer know you are here today? If you answered yes to any question, explain below. A yes response is not necessarily a bar for Employment.
CERTIFICATION AND AGREEMENT I certify that all information given on this application is true and correct. I also certify that I have accounted for all of my work experience and training on this application. I understand that any misstatements or omissions on this application will result in a decision not to hire me, or to discharge me if discovered after I am hired. It is my understanding that Champlain Enterprises, Inc. will make a thorough investigation of my entire work and personal history to include my driving record and any FAA licenses, and may verify all data given in my application for employment, related papers or oral interviews. Additionally, I understand that by FAA regulation, my fingerprints must be taken and submitted for an official criminal history check. I further understand that Champlain Enterprises, Inc. may obtain the results of any drug tests or alcohol tests conducted at previous and/or present employers under terms and conditions of the DOT/FAA Alcohol Misuse Prevention Program. I authorize such investigation and the giving and receiving of any information requested by Champlain Enterprises, Inc., and I release from liability any person giving or receiving any such information. I understand that omission or falsification of data given or other derogatory information discovered as a result of this investigation will prevent my being hired, or if hired, will subject me to immediate dismissal. I understand that I will be required to pass a test (urine drug screen) designed to detect the illegal use of drugs. I understand that failure to take or to pass this test will preclude my employment with Champlain Enterprises, Inc. I also understand that I may be required to pass a breath alcohol test, and that failure to take or pass this test will preclude my employment with Champlain Enterprises, Inc. I further understand that I may be required to submit to drug and alcohol breath testing during my employment with Champlain Enterprises, Inc. and agree to submit to any such tests, whether announced or not. I understand that I may be required to complete a medical inquiry form, which will enable Champlain Enterprises, Inc. to assess my medical history. I also understand that it may be necessary to assist Champlain Enterprises, Inc. in this assessment by providing access to my medical records. I further understand that I may be required to submit to a physical examination to determine my fitness to perform the essential functions of the position, for which I am applying within Champlain Enterprises, Inc. I understand that as a flight crew member I will be required to produce a current and valid first-class medical certificate. I agree that if I am employed by Champlain Enterprises, Inc., all copyrightable materials, inventions, trademarks, service marks, promotional ideas, processes and products related to Champlain Enterprises, Inc. or to my employment, conceived or developed by me, will become the property of Champlain Enterprises, Inc. without compensation; provided, however, that for any ideas submitted in connection with a Company sponsored suggestion program, I will receive compensation consistent with the terms and conditions of said program. I understand that if I am employed, such employment is for an indefinite period and that Champlain Enterprises, Inc. can change wages, benefits, and conditions at any time; I am an At Will Employee. I agree to report any suspected discrimination or harassment in the workplace, if hired, to Human Resources immediately. I understand that I waive any right to a jury trial on claims related to my employment and waive any right to be a member of a class action on claims related to my employment. I understand that if I am offered employment, Champlain Enterprises, Inc. will require me to produce certain documents within three business days of my hire date in order to comply with the Immigration Reform and Control Act of 1986. I further understand that any offer of employment is contingent upon providing the appropriate documents. I further understand that this is an application for employment and that no employment contract is being offered. I have read and understand the above. Signature Date
Champlain Enterprises, Inc. Operated by CommutAir THIS IS A DRUG FREE WORKPLACE Persons applying for any position, including SAFETY SENSITIVE POSITIONS as outlined below, are subject to pre-employment drug testing for: Marijuana, Cocaine, Opiates, Phencyclidine (PCP), Amphetamines and Ecstasy (MDMA) or a Metabolite of those drugs. All applicants must receive a verified negative drug test result prior to beginning employment with CommutAir. SAFETY SENSITIVE FUNCTIONS (FAA regulation 14 CFR part 120) Flight Crewmember Flight Attendant Aircraft Dispatcher Aircraft Maintenance and Preventative Maintenance Ground Security Coordinator Aviation screening Air Traffic Control
PRE-EMPLOYMENT DRUG TEST RELEASE Champlain Enterprises, Inc. dba CommutAir is required by FAA Regulations to conduct DOT/FAA regulated pre-employment drug testing for employees who perform the following safety-sensitive functions: Flight Crewmember, Flight Attendant, Flight Instruction, Aircraft Dispatcher, Aircraft Maintenance or Preventative Maintenance, Aviation Screening, Air Traffic Control and Ground Security Coordinator. Applicants for any other job functions are also subject to pre-employment drug testing following the same procedures and guidelines. I understand that I will undergo a urine drug screening test for the following drugs: Marijuana, Cocaine, Opiates, Amphetamines, Ecstasy (MDMA) and Phencyclidine (PCP) Therefore, I authorize the submission of the results to CommutAir. A verified positive test result, a verified adultered specimen as well as a refusal to test will result in immediate withdrawal of the offer of employment. Additionally, I hereby authorize the release of the results of any previous drug and alcohol tests conducted by any former employer to CommutAir in accordance with regulations set forth by FAA (14 CFR Parts 61, 63, 65, 120, 121 and 135) and DOT (49 CFR Part 40.25) I understand that as an employee of CommutAir, I will be subject to random, post-accident, reasonable cause, return to duty and follow up drug testing as outlined in the company s Drug and Alcohol Misuse and Prevention Policy and FAA guidelines. I have been briefed on and understand the policies and procedures to be followed for pre-employment drug testing with Champlain Enterprises, Inc. dba United Express/CommutAir. I understand that my employment at CommutAir for the position of is contingent upon passing the preemployment drug screen. (Job Description) Applicant Name Social Security # Witness Name Signature Signature Date Date PLEASE RETURN TO PETRA KLIMAN ANTI-DRUG/ALCOHOL PROGRAM MANAGER