SCHOOL BUS DRIVER APPLICATION SCHOOL CITY OF HOBART SERVICE CENTER 200 SOUTH HOBART ROAD HOBART, INDIANA 46342 Social Security # Contact Phone # Name (Last) (First) (Middle) Permanent Address (Street) (City, State) (Zip) Driver s License # (State) (Exp. Date) Commercial Driver s License # (State) (Exp. Date) Commercial Driver s License Class Air Brake: Yes No Passenger: Yes No Years of driving experience: Auto School Bus Other (explain) Has your driver s license ever been suspended or revoked: Yes No If Yes, (explain) Do you own your own car? Name of auto insurance company In case of emergency, whom shall we notify? Name Relationship Phone Address
PRESENT AND PAST EMPLOYMENT RECORD List below a complete employment history beginning with your most recent:
DRIVER-APPLICANT AUTHORIZATION TO RELEASE DRUG AND ALCOHOL TEST INFORMATION In conformity with sections 382.413, 382.405 and 391.89 of Title 49 of the Code of Federal Regulations, I hereby authorize the carriers listed below to furnish the School City of Hobart the following information concerning drug and alcohol tests, including pre-employment tests, the carriers conducted during the post two years: (i) the dates on which I tested positive for drugs, and the drug(s) involved; (ii) the dates on which I tested 0.02 or greater for alcohol and the test result levels; (iii) the dates on which I refused to be tested for drugs and/or alcohol. I fully understand that the information I authorize the School City of Hobart to receive involves tests which were required by the Department of Transportation (DOT), and may also include information concerning tests which DOT did not require but with the carriers listed below may have voluntarily conducted under their own authority unless I instruct the carriers in writing not to release information concerning non-dot tests. If any carrier listed below furnishes information concerning items (I,II) or (III), I also authorize that carrier to releases and furnish: (iv) the dates of my negative drug tests and/or alcohol tests and/or tests with results below 0.02 during the two-year period; and (v) the name and phone number of any substance abuse professional who evaluated me during the past two years. (Please print clearly) Termination Date Name of Company City and State Phone Number (Attach additional form if needed) By signing below, I certify that I have read the fully understand this release, that prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction, and that I executed this release voluntarily and with knowledge that the information being release could affect my being hired. I further certify that all of the information which have furnished on this form is true and complete, and that I have listed every company that I worked for as a driver during the past two years and every company that I took a pre-employment drug and/or alcohol test for during the past two years. The School City of Hobart is an Equal Opportunity Employer. The School City of Hobart ensures equal employment opportunities regardless of race, creed, sex, color, national origin, religion, age, sexual orientation or disability. The School City of Hobart has a policy of active recruitment of qualified minority teachers and non-certified employees. Any individual needing assistance in making application for any opening should contact the Department of Human Resources. Print Name: Social Security # (Applicant name) Signed: Date: (Applicant signature required) App Bus.doc 5/20/2010
SCHOOL CITY OF HOBART 32 EAST 7TH STREET HOBART, IN 46342 Dear Applicant: In order to be considered for employment in the School City of Hobart, you must fully complete the following questionnaire and sign it. Dr. Peggy Buffington Superintendent 1. Are you presently being investigated or under a procedure to consider your discharge for misconduct by your present employer or have you offered a resignation to your previous employer? If yes, explain the circumstances on a separate sheet and attach to this application. 2. Have you ever been reprimanded, disciplined, discharged, or asked to resign from a prior position? If yes, explain the circumstances on a separate sheet and attach it to this application. 3. Have you ever resigned from a prior position without being asked, but under circumstances involving your employer's investigation of sexual contact with another person, of mishandling of funds, or of criminal conduct? If yes, explain the circumstances on a separate sheet and attach it to this application. 4. Have you ever been charged with or investigated for sexual abuse of another person? 5. Have you ever been charged with, pleaded guilty or "no contest" (nolo contendere) to, or been convicted of any crime involving sexual abuse of any person or any other crime of moral turpitude? (Moral turpitude is an act of baseness, vileness or depravity in the private and social duties which a person owes another member of society or society in general and which is contrary to the accepted rule of right and duty between persons, including but not limited to theft, attempted theft, murder, rape, swindling and indecency with a minor.) 6. Have you (a) ever been convicted of a crime, other than a minor traffic offense; or (b) ever entered a plea of guilty or a plea of "no contest" (nolo contendere), or (c) has any court ever deferred further proceedings without entering a finding of guilty and placed you on probation, for any crime other than a minor traffic offense? If you have answered yes to any one of the previous three questions, please explain in detail on a separate sheet and attach it to this application; include the date of the charge, the court action, the offense in question, and the address of the court involved.
Conviction of a crime is not an automatic bar to employment. The School City will consider the nature of the offense, the date of the offense, and the relationship between the offense and the position for which you are applying. Any false or misleading information shall be fully sufficient grounds to refuse to employ or, having been employed, shall be immediate cause for dismissal. My signature below constitutes authorization for the School City of Hobart to check my employment history, including without limitation, evaluations; checks on attendance, character, attitude, and dependability; reference checks; and release of investigatory information, including a limited criminal history, possessed by any private or public employer or any state, local or federal agency. I further authorize those persons, agencies or entities that the School City of Hobart contacts in connection with my employment application to fully provide the School City of Hobart any information on the matters set forth above and I will cooperate to the extent necessary to obtain the release of this information. I expressly waive in connection with any request for or provision of such information, any claims, including without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the School City of Hobart, its officials, employees, trustees or agents, or against any provider of such information. The School City of Hobart is an Equal Opportunity Employer. The School City of Hobart ensures equal employment opportunities regardless of race, creed, sex, color, national origin, religion, age, sexual orientation or disability. The School City of Hobart has a policy of active recruitment of qualified minority teachers and non-certified employees. Any individual needing assistance in making application for any opening should contact the Department of Human Resources. I HAVE READ THIS AUTHORIZATION AND RELEASE OF ALL CLAIMS, AND I EXPRESSLY AGREE TO THE TERMS SET OUT HEREIN. Date Applicant's Signature Applicant's Name Printed/Typed BKGRDINF 5/19/2010