111 Professional Court
Frankfort, Kentucky 40602
APPLICATION FOR EMPLOYMENT
PERSONAL / LAST NAME FIRST MIDDLE / DATESTREET ADDRESS / HOME PHONE
CITY, STATE, ZIP / BUSINESS PHONE
HAVE YOU EVER WORKED WITH US BEFORE?
YES NO If Yes: Month & Year Location / LAST 4 DIGITS OF SOCIAL SECURITY NO
POSITION DESIRED / PAY EXPECTED
ARE YOU AVAILABLE FOR FULL-TIME WORK? YES NO If not, what hours can you work? / WILL YOU WORK OVERTIME IF ASKED? YES NO
ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES? / WHEN WILL YOU BE AVAILABLE TO BEGIN WORK?
HAVE YOU EVER WORKED UNDER ANOTHER NAME? (What: )
OTHER SPECIAL TRAINING OR SKILLS (Languages, machine operation, etc.)
HOW DID YOU LEARN OF OUR ORGANIZATION?
DO ANY OF YOUR RELATIVES WORK HERE? YES NO IF YES, WHO IS THE RELATIVE?
STATE AGE IF UNDER 18:
TRANSPORTATION AVAILABLE FOR JOB IF REQUIRED? YES NO
E D U C A T I O N / School / Name and Location of School / Course of Study / No. of Years Completed / Did you Graduate / Degree or Diploma
Elementary / YES
NO
High School / YES
NO
College / YES
NO
Other / YES
NO
MEMBERSHIP IN PROFESSIONAL OR CIVIC ORGANIZATIONS
(Exclude those which may disclose your race, color, religion, or national origin)
EMPLOYMENT / Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer.
1 / Company Name / Telephone
Address / Employed (State Month and Year)
From To
Name of Supervisor / Weekly Pay
Start Last
State Job Title and Describe Your Work / Reason for Leaving
2 / Company Name / Telephone
Address / Employed (State Month and Year)
From To
Name of Supervisor / Weekly Pay
Start Last
State Job Title and Describe Your Work / Reason for Leaving
3 / Company Name / Telephone
Address / Employed (State Month and Year)
From To
Name of Supervisor / Weekly Pay
Start Last
State Job Title and Describe Your Work / Reason for Leaving
4 / Company Name / Telephone
Address / Employed (State Month and Year)
From To
Name of Supervisor / Weekly Pay
Start Last
State Job Title and Describe Your Work / Reason for Leaving
5 / Company Name / Telephone
Address / Employed (State Month and Year)
From To
Name of Supervisor / Weekly Pay
Start Last
State Job Title and Describe Your Work / Reason for Leaving
We may contact the employers listed above unless
you indicate those you do not want us to contact. / DO NOT CONTACT
Employer Number(s) Reason
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Y / COMPLETE THIS SECTION IF YOU
SERVED IN THE U.S. ARMED FORCES / Branch of Service
Describe your duties and any special training. / Period of Active Duty (Month/Year)
From To
Rank at Discharge
Date of Final Discharge
PERSONAL REFERENCES (not relatives or former employers)
Name / Occupation / Complete Address / Phone No.Summarize special skills and qualifications acquired from employment, education or other experience
Professional licenses or certificates (include license or certificate number) you hold
State any additional information you feel may be helpful to us in considering your application
To comply with state and federal requirements, certain Agency programs mandate a criminal record check as a condition
of employment.
I, the applicant named in the above (forgoing), do certify that the information contained herein is true, correct and
complete to the best of my knowledge and belief. I am aware that, should investigation at any time disclose any mis-
representation or falsification, my application will be rejected, my name will be removed from consideration, and it
shall constitute grounds for my dismissal. I authorize Blue Grass CAA to make the necessary and appropriate investi-
gation to verify the information contained herein.
(Date)(Signature)
THIS APPLICATION WILL BE CLASSIFIED ACTIVE FOR 3 MONTHS. AT THE END OF THAT PERIOD YOU SHOULD REAPPLY IF YOU ARESTILL INTERESTED IN EMPLOYMENT
APPLICANT – Do not write on this page
FOR INTERVIEWER’S USE
RE
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EQUAL OPPORTUNITY EMPLOYER
Serving Anderson, Boyle, Franklin, Garrard, Jessamine, Lincoln, Mercer, Scott, and Woodford Counties
To monitor the effectiveness of the Agency’s Affirmation Action Program, we request that you voluntarily complete the following information. This form will be detached and filed separately.
CountyState
Age: Under 40 Over 40
Race: Asian Black/African American Hispanic/Latino
Native Hawaii/Pacific Islander Two or More Races White
Gender: Male Female
Handicapped: Yes No
Veteran: Yes No
Position applied for:
Employee Name (Printed)Date
Employee Signature
Attachment IV
APPLICANT ACKNOWLEDGMENT OF DRUG TEST REQUIREMENTS
I understand that as a part of my application for employment, I must successfully complete a USDOT drug test as required by 49 CFR Part 655. I understand that a negative test result is required before I will be considered for hire. I also understand that I will be subject to Drug and Alcohol Testing provisions of 49 CFR parts 40 as amended and 655 throughout my period of employment in a USDOT/FTA/FMCSA safety—sensitive position.
Signature of ApplicantWitness
DateDate
TimeTime
YOUR APPLICATION WILL BE CONSIDERED INCOMPLETE IF THIS NOTICE ISNOT SIGNED AND DATED!