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Application for Employment (DOT)

Air Serv Corporation is an Equal Opportunity Employer

GENERAL INFORMATION

Failure to provide complete information may result in denial of your application. Please type or print clearly using black or dark blue ink only. If you need additional space for any section of this application, attach separate sheets of paper, clearly labeled, as necessary. Make certain all required attachments to this application are present when you submit it. Incomplete applications that are pending additional information will not be considered until all information and attachments are received. Information provide in this application will be kept confidential unless the applicant consents otherwise. Providing false information on this application is a violation of State and Federal laws.

I understand that filling out this form does not indicate there is a position open and does not obligate Air Serv to hire me. If hired, I agree to abide by Air Serv’s work rules, policies and procedures relating to work performance and conduct.

No person shall be denied employment consideration on the basis for race, color, ethnicity, national origin, sex/gender, religion, creed, age, sexual orientation, marital status, veteran status, or disability. I am fully aware that, if employed, I will be an AT-WILL employee. Either Air Serv or I may end my employment with or without notice, and with or without cause at any time.

______________________________________

____________________

Applicant Signature

Date

APPLICANT’S FULL NAME:

Last

First

Middle

Previous names used:

Social Security #

CURRENT MAILING ADDRESS:

Street Address

Apt. #

City

State

Zip Code

TELEPHONE NUMBER(S):

EMAIL ADDRESS:

Day (

)

Evening (

)

Cell ( )

EMPLOYMENT INFORMATION

Date available to begin work:

Days/hours you are unable to work:

Shift Preferred:

Full Time

Hours Desired:

Part Time

Intern/Temp

How did you hear about us?

Employee Referral - Referred by: _________________________________________________________________________

School

Air Serv Corporation Website

Newspaper _________________________________

Other ______________________________________

Have you been previously employed by Air Serv Corporation?

If YES, please list:

Yes

Dates of Service:

Position(s):

• If hired, can you provide citizenship or the legal right to work in the United States?

Yes

(Employment is contingent upon evidence of identity and eligibility.)

• Have you ever been convicted of a felony or misdemeanor?

Yes

If YES, attach a detailed explanation of the conviction and any subsequent time spent in jail or prison.

• Have you ever been convicted of Driving While Under the Influence of Alcohol or

Under the Influence of a Controlled Substance?

Yes

If YES, please attach a detailed explanation of the conviction.

Page 1 of 4

EDUCATION

Prior to any offer of employment being made, you may be asked to provide copies of your school diploma(s), certificate(s), and/or transcripts.

Circle number of years completed at each level:		High School 1 2 3 4	College 1 2	3 4
	Name	Location	Did you graduate?		GED, Diploma or degree

High School

College

Other

U.S. MILITARY SERVICE

Service Branch:

Area of Specialization:

Final Route or Ration:

Length of Service:

SPECIAL SKILL/KNOWLEDGE

List any special skills/knowledge/training that you consider relevant to your employment qualifications:

Language Ability: Please indicate any language(s) in which you are proficient.

English: Speak Read

Write

Other:

Speak

Read

Write

Other:

Speak Read Write

Other:

Speak

Read

Write

MOTOR VEHICLE INFORMATION AND DRIVING EXPERIENCE

Driver’s License #:

State:

Expiration Date:

Class Type:

Endorsement(s):

Restrictions:

Type of Equipment

How Long

Location

Driving

Experience

Accident Record: List accidents for the past three (3) years beginning with the most recent (attach additional sheet if necessary)

Accident Date

Nature of Accident

Fatalities

Injuries

Traffic Violations (other than parking violations): List violations for the past three (3) years beginning with the most recent (attach

additional sheet if necessary)

Location

Date

Charge

Penalty

•	Have you ever been denied a license, permit, or privilege to operate a motor vehicle?	Yes	No
•	Has any license, permit, or privilege ever been suspended or revoked?	Yes	No
	(If you answered ‘YES’ to either of the questions above, attach a detailed explanation.)

APPLICANT ACKNOWLEDGMENT OF COMPANY DRUG TESTING

As a condition of employment with this Company, I understand that, in accordance with FAA Anti-Drug Testing Program, Department of Transportation (DOT) Regulations, and Air Serv Corporation Company Policy, I will be required to take a pre-employment drug test. The Company must receive a negative result from this testing prior to the completion of my employment process.

The Anti-Drug Program and DOT Regulations require urine and/or saliva testing for the following five specific drugs – marijuana, cocaine, opiates, amphetamines, and PCP. If hired, I further understand that I will be part of the Company’s ongoing Drug/Alcohol Abuse testing program which includes random, reasonable suspicion, post accident, return to duty and follow-up testing.

If I either refuse to cooperate with the mandatory drug/alcohol testing program as implemented by Air Serv Corporation, or if I have a verified positive drug test reported to the Company after the careful review of the Medical Review Officer, I understand that I will not be considered for employment.

_______________________	________________________	_______________
Applicant Name (please print)	Applicant Signature	Date

Page 2 of 4

10 YEAR EMPLOYMENT / BACKGROUND HISTORY – Page 1 of _______ (Additional page available if needed)

Federal Law requires that personnel considered for certain airline duties are subject to a full 10-year employment history verification and possibly a criminal records check.

•Employment / background history must be listed for the previous ten (10) years, including all gaps in employment. (Use an extra piece of paper if necessary.)

•All employment gaps of TWO (2) CONSECUTIVE MONTHS OR MORE during this 10-year period require published verification. (Examples: unemployment records/receipts, official school records, medical records.)

•A fingerprint-based criminal records check may be necessary for certain job classifications, and/or:

1)If any 12 month period of unemployment cannot be satisfactorily accounted for.

2)If the applicant is unable to support statements made, or there are significant inconsistencies in the information provided with regard to gaps in employment and information obtained through the verification process.

Current (or most recent) Employer:

Supervisor’s Name:

Address:

Telephone:

Fax:

Employment Dates:

Position Held:

Reason for Leaving:

May we contact this employer?

YESNO

FOR EMPLOYER USE ONLY

VERIFIED WITH: ________________________________ VERIFIED BY: _________________________________ DATE: ______________

COMMENTS:

Employer:

Address:

Employment Dates:

Reason for Leaving:

Supervisor’s Name:

Telephone:

Position Held:

Fax:

FOR EMPLOYER USE ONLY

VERIFIED WITH: ________________________________ VERIFIED BY: _________________________________ DATE: ______________

COMMENTS:

Employer:

Address:

Employment Dates:

Reason for Leaving:

Supervisor’s Name:

Telephone:

Position Held:

Fax:

FOR EMPLOYER USE ONLY

VERIFIED WITH: ________________________________ VERIFIED BY: _________________________________ DATE: ______________

COMMENTS:

I certify that all information which I have given is true, and I understand that any misrepresentation or omission of facts called for in this form is grounds for any employment offer made to be rescinded, or any employment or training already underway to be terminated immediately.

All information provided is subject to verification. By signing this document, I authorize Air Serv Corporation to thoroughly investigate my background, references, employment record and other matters related to my suitability for employment. Furthermore, I authorize my former employers or any third party to disclose to Air Serv all reports and other information related to my suitability for employment, personal or otherwise, without giving me prior notice of such disclosure. In addition, I hereby release Air Serv, former employers and all references listed above from any and all claims, demands and liability arising out of or related to such to make a consumer credit report in connection with this application.

_______________________	________________________	_______________
Applicant Name (please print)	Applicant Signature	Date
	Page 3 of 4

AUTHORIZATION FOR BACKGROUND INVESTIGATION

I, ____________________________________________, hereby authorize Air Serv Corporation and/or its agents to make an

independent investigation of my background, which may include my character, general reputation, personal characteristics, and mode of living in connection with an application of employment with Air Serv Corporation.

The scope of the report may include information concerning my driving record, civil and criminal court records, worker’s compensation record, education, credentials, identity, past addresses, social security number, previous employment, and personal references.

I authorize and request any present or former employer, state/federal government office, state department of motor vehicles, credit bureaus, school, police department, court records, including those maintained by both public and private organizations, financial institution, or other persons having personal knowledge about me to furnish Air Serv Corporation and/or its agents with any and all information in their possession regarding me for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualifications for employment. I consent that a photocopy of this authorization be accepted with the same authority as the original, and I specifically waive any written notice from any present or former employer who may provide information upon this authorization request.

The following is my true and complete legal name and all information is true and correct to the best of my knowledge:

Full Name (print): _________________________________________________________________________________________________

Maiden Name or Other Names Used (print): ___________________________________________________________________________

Date of Birth: _______________________		Social Security Number: ___________________________________
Driver’s License Number: __________________________________		State of Issue: ____________________________________
Phone: ______________________________	Cell: ____________________________________

Please provide all residential addresses for the past 10 years, beginning with the current one.

Street Address

City/State/Zip Code

Years at Address

I understand my signature below acknowledges that I have read and understand this form and waive any rights I may have to bring action for defamation, invasion of privacy, or any similar cause against Air Serv Corporation and/or its agents.

Signature: ______________________________________________________________________________________

Date: ________________________

Page 4 of 4

DOT APPLICANT QUESTIONNAIRE

PREVIOUS DRUG AND ALCOHOL TESTING INFORMATION

Applicants MUST answer the following questions. Please respond by checking Yes or No after each of the following questions. These questions are required by US Department of Transportation Regulation 49 CFR Part 40.

In the Past Two Years:
1.	Have you had any DOT required alcohol test with a result of 0.04 or higher
	alcohol concentration?	Yes	No
2.	Have you had any verified (by the Medical Review Office) positive DOT required
	drug/alcohol tests?	Yes	No
3.	Have you refused to be tested (including having a verified adulterated or
	substituted drug test result)?	Yes	No
4.	Have you had any other violation of DOT agency drug or alcohol testing
	regulation?	Yes	No
5.	Were there any situations in which you tested positive on a pre-employment
	test for a DOT employer that did not hire you?	Yes	No
6.	Were there any situations in which you refused to submit (including having an
	adulterated or substituted finding) to a pre-employment test for a DOT
	employer that did not hire you?	Yes	No

I certify that my responses to the above questions are true:

_____________________________________________________________	________________________
Signature	Date
_____________________________________________________________	________________________
Print Name	Social Security Number

AUTHORIZATION TO RELEASE MOTOR VEHICLE RECORD

I hereby give consent, without any reservation, for Air Serv and/or its agents to obtain a copy of my driving record as part of a pre-employment background check for Air Serv Corporation.

I agree that a telephone facsimile (fax) or photographic copy shall be valid as the original.

I certify and understand, as my signature below acknowledges, that I have read this form and waive any rights I may have to bring criminal and/or civil action for defamation, invasion of privacy, or any similar cause against Air Serv Corporation and/or its agents.

Please provide the following information:

Name (As it appears on your drivers’ license): ________________________________________

Drivers’ License Number: ________________________________ State: _______________

Social Security Number: _______________________________

Date of Birth (Month/Day/Year): ________________________________

____________________________________	____________________________________
Signature	Date

______________________________	______________________________
Witness Signature	Date

JURY TRIAL WAIVER AGREEMENT

The Company hopes that, if you become employed, your experience will be a positive one. We also firmly believe that our internal complaint resolution procedures should be sufficient to resolve any problems that may arise between you and the Company. However, we recognize that sometimes, despite everyone’s best efforts, a matter cannot be resolved internally. In those rare instances, we believe that judges are in the best position to fairly resolve these disputes.

This document is a Jury Trial Waiver Agreement (“Agreement”). In exchange for the Company’s consideration of your application for employment and your actual employment (if hired), you are being asked to sign this Agreement as a condition of being employed by the Company. Because we believe that judges are best suited to resolve disputes between you and Company, if you choose to sign this Agreement, the Company also will waive its right to request or demand a jury trial with respect to any lawsuit between you and the Company.

This Agreement does not prevent you from filing charges with administrative agencies such as the Equal Employment Opportunity Commission or the National Labor Relations Board or equivalent state agencies. This Agreement does not take away any of your rights to sue or to seek all of the types of remedies the law allows. It simply provides that a judge will decide any differences that cannot be resolved through the Company’s internal complaint resolution procedures. By signing this Agreement, you waive your right to request or demand a jury trial with respect to any claims under federal or state law (to the extent permitted by the law of the state in which you may be employed) that you may assert against Air Serv Corporation, its affiliates, subsidiaries, divisions, successors, assigns, purchasers, and/or its current, former, and future employees, shareholders, officers, directors and agents (“the Company”). This includes, but is not limited to, claims relating in any manner to your application for employment, your employment (and any of its terms or conditions), or your separation from employment with the Company.

You may choose to reject this Agreement. If you choose not to sign this Agreement, you will not be hired (or, if hired, you will not remain employed) by the Company. If you decide not to sign this Agreement today, you may take it with you and you may consult with any attorney of your choosing to discuss this Agreement before signing it. You may take as much time as you want to consider this Agreement, but you will not be considered for an open position until you have submitted a complete application (including this Agreement).

This Agreement constitutes the entire agreement and understanding between you and the Company and supersedes any prior agreements and understandings, whether written or oral, related to its subject matter. This Agreement cannot be revoked or modified except by a written agreement, signed by you and the General Counsel of the Company. Nothing in this Agreement shall be construed to create an offer of employment or a contract for a definite term of employment, express or implied, or to alter any at-will employment relationship.

IMPORTANT: BY SIGNING BELOW, I AGREE THAT I HAVE HAD AS MUCH TIME AS I WANTED TO CONSIDER THIS AGREEMENT AND THAT I UNDERSTAND I AM GIVING UP AND WAIVING MY RIGHT TO A JURY TRIAL KNOWINGLY, INTELLIGENTLY, VOLUNTARILY, AND FREE FROM DURESS OR COERCION.


Date		Candidate Signature

Question	Answer
Form Name	Airsev Application For Employment Form
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	successors, classifications, PCP, 10-year

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