DRIVER APPLICATION FOR EMPLOYMENT

Form
Name*

First NameLast Name
Social Security Number*
no spaces or dashes
Today's Date

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Time Living There
mm/yyyy - mm/yyyy
Emergency Contact*
Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Have you worked for a school district in PA before?

YesNo
Are you available Monday - Friday with a split Schedule? Working morning, off mid day and then working again afternoons?*

YesNo
Date you can start

MonthDayYear
Date
Are you lawfully eligible to work in this country with a valid immigration status or are you a citizen?*

YesNo
Country of Citizenship*
If you do not have US Citizenship, please type the country you are still a current citizen of.
Birth Country*
Which Country were you born in?
City of Birth*
Which City were you born in?
Have you ever been convicted of a felony?*

YesNo
Driver's License Number*
State*
Expiration Date*

MonthDayYear
Date
Driver's License Type (Standard or CDL)
Highest Education
Date Completed

MonthDayYear
Date
Height*
Weight*
Hair Color*
Eye Color*
Car Year*
VIN Number*
Car Make*
Car Model*
Mileage
Signature*

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Date

MonthDayYear
Date

ARREST/CONVICTION REPORT AND CERTIFICATION FORM (under Act 24 of 2011 and Act 82 of 2012)
Name

First NameLast Name
Date of Birth*

MonthDayYear
Date
Other Names by which you have been identified
By checking this box, I state that I have NOT been arrested for or convicted of any Reportable Offense.

Please Click Here
By checking this box, I state that I have NOT been arrested for or convicted of any Reportable Offense.

Please Click Here
By checking this box, I report that I have been arrested for or convicted of an offense or offenses enumerated under 24 P.S. §§1-111(e) or (f.1) (“Reportable Offense(s)”). See Page 3 of this Form for a list of Reportable Offenses.
For each arrest for or conviction of any Reportable Offense, specify in the space below (or on additional attachments if necessary) the offense for which you have been arrested or convicted, the date and location of arrest and/or conviction, docket number, and the applicable court.
By checking this box, I state that I have NOT been named as a perpetrator of a founded report of child abuse within the past five (5) years as defined by the Child Protective Services Law.

Please Click Here
By checking this box, I state that I have NOT been named as a perpetrator of a founded report of child abuse within the past five (5) years as defined by the Child Protective Services Law.

Please Click Here
By checking this box, I report that I have been named as a perpetrator of a founded report of child abuse within the past five (5) years as defined by the Child Protective Services Law.
By signing this form, I certify under penalty of law that the statements made in this form are true, correct and complete. I understand that false statements herein, including, without limitation, any failure to accurately report any arrest or conviction for a Reportable Offense, shall subject me to criminal prosecution under 18 Pa.C.S. §4904, relating to unsworn falsification to authorities.*

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Today's Date

MonthDayYear
Date

COMMONWEALTH OF PENNSYLVANIA SEXUAL MISCONDUCT/ABUSE DISCLOSURE RELEASE (under Act 168 of 2014)

Hiring school entity or independent contractor submits this form to ALL current employer(s) and to former employer(s) that were school entities and/or where the applicant had direct contact with children)
No applicable employment

Check here if you never were employed with a company in which you dealt directly with children as your main job
Name

First NameLast Name
Any former names by which the applicant has been identified, if no other aliases leave blank
Date of Birth

MonthDayYear
Date
Last 4 digits of Applicant's Social Security Number:*
Have you ever been the subject of an abuse or sexual misconduct investigation by any employer, state licensing agency, law enforcement agency or child protective services agency (unless the investigation resulted in a finding that the allegations were false)?

YesNo
Have you ever been disciplined, discharged, non-renewed, asked to resign from employment, resigned from or otherwise separated from employment while allegations of abuse or sexual misconduct were pending or under investigation or due to adjudication or findings of abuse or sexual misconduct?

YesNo
Have you ever had a license, professional license or certificate suspended, surrendered or revoked while allegations of abuse or sexual misconduct were pending or under investigation or due to an adjudication or findings of abuse or sexual misconduct?

YesNo
By signing this form, I certify under penalty of law that the statements made in this form are correct, complete, and true to the best of my knowledge. I understand that false statements herein, including, without limitation, any willful failure to disclose the information required, shall subject me to criminal prosecution under 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities) and to discipline up to, and including, termination or denial of employment, and may subject me to civil penalties and disciplinary action under the Educator Discipline Act. I also hereby authorize the above-named employer to release to the entity listed on page 3, the information requested in SECTION 2 of this form and any related records. I hereby release, waive, and discharge the above-named employer from any and all liability of any kind that may arise from such disclosure or release of records. I understand that third party vendors may be used to process this Act 168 pre-employment history review.*

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Todays Date

MonthDayYear
Date

Only complete this section below If you have worked at a former job in which you had direct contact with children as a main part of your job. Please list that employer below
Name of employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
example@example.com
Contact Person Title
Contact Person Name
Approximates dates of employment with the entity listed above
Position(s) held with the entity

Click the arrow button to the right & then click Next to go to the next page

REQUEST FOR DRIVER INFORMATION

Pennsylvania Department of Transportation (Driver History Request form)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date Of Birth

MonthDayYear
Date
Driver's License Number
I Name of Driver hereby request the Department of Transportation to furnish a copy of my PA Driver's Record to Samba Safety.
Signature*

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Date

MonthDayYear
Date

CONSENT AND DIRECTION TO RELEASE DRUG AND ALCOHOL TESTING INFORMATION
The following individual (“Enrollee”) has been enrolled in the Consortium (1st Class Transit LLC). Pursuant to the Consent signed below, the Consortium (1st Class Transit LLC) is to provide ALC Schools, LLC (“ALC”) with the types of testing results and information indicated below for the Enrollee named on this form. The Enrollee named herein does hereby authorize and direct the Consortium (1st Class Transit LLC) named herein, and Consortium (1st Class Transit LLC) hereby agrees, within 24 hours of such results/information being available, to release and provide via email or fax all results and information relating to drug and/or alcohol testing performed on any specimens provided by Enrollee, including any and all records, charts, reports, notes, documents, correspondence and status of enrollment in the drug and alcohol testing program described above to the ALC addresses and numbers provided to the Consortium (1st Class Transit LLC)
Consortium (1st Class Transit LLC) is also authorized and directed to release and agrees to release and provide the following to ALC:1. This form as confirmation of Enrollee’s enrollment in Consortium’s (1st Class Transit LLC) program;2. Copy of Consortium’s (1st Class Transit LLC) policies and procedures (unless already on file with ALC);3. Email alert (within 24 hours) when Enrollee has been removed from the program; and4. Confirmation that program will supply ALC with annual reporting on random testing numbers.
Name

First NameLast Name
Last 4 of Social Security Number*
Signature*

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Date

MonthDayYear
Date
Date

MonthDayYear
Date

PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION
Name

First NameLast Name
Middle Name
If you do not have a middle name type NONE or NMN
Social Security Number
Format XXX - XX - XXXX
Gender

MaleFemaleNot reported
Date of Birth

MonthDayYear
Date
Current Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Phone Number
Please enter a valid phone number.

Only complete this section if you have used any other previous name since 1975
Previous Name 1

First NameLast Name
Previous Name 2

First NameLast Name

Name the last 3 addresses you have lived OR any other 3 addresses you have lived since 1975
Previous Address 1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

HOUSEHOLD MEMBERS(Please list everyone who lived with you at any time since 1975 to present.Please include parent, guardian or the person(s) who raised you; attach additional pages as necessary.)
Father Name*
First, Middle, Last
Father Current Age OR the Age he died*
Father Gender
Type: Male, Female, or They
Mother Name*
First, Middle, Last
Mother Current Age OR the Age she died*
Mother Gender
Type: Male, Female, or They
Spouse Name
First, Middle, Last
Spouse Current Age OR the Age Spouse died
Spouse Gender
Type: Male, Female, or They
Sibling 1 Name
First, Middle, Last
Sibling 1 Current Age OR the Age Sibling 1 died
Sibling 1 Gender
Type: Male, Female, or They
Sibling 2 Name
First, Middle, Last
Sibling 2 Current Age OR the Age Sibling 2 died
Sibling 2 Gender
Type: Male, Female, or They
Sibling 3 Name
First, Middle, Last
Sibling 3 Current Age OR the Age Sibling 3 died
Sibling 3 Gender
Type: Male, Female, or They
Child 1 Name
First, Middle, Last
Child 1 Current Age OR the Age Child 1 died
Child 1 Gender
Type: Male, Female, or They
Child 2 Name
First, Middle, Last
Child 2 Current Age OR the Age Child 2 died
Child 2 Gender
Type: Male, Female, or They
Child 3 Name
First, Middle, Last
Child 3 Current Age OR the Age Child 3 died
Child 3 Gender
Type: Male, Female, or They
Child 4 Name
First, Middle, Last
Child 4 Current Age OR the Age Child 4 died
Child 4 Gender
Type: Male, Female, or They

SIGNATURE - I affirm that the above information is accurate and complete to the best of my knowledge and belief and submitted as true and correct under penalty of law (Section 4904 of the Pennsylvania Crimes Code). If I selected volunteer, I understand that I can only use the certificate for volunteer purposes.
Signature*

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Date

MonthDayYear
Date

The School District Of Philadelphia Driver Credential Authorization and Certification Release Form
Name

First NameLast Name
Driver's License Number
8 digits
State Driver's License Issued
Date Of Birth

MonthDayYear
Date
Signature*

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MonthDayYear
Date
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Form

ARREST/CONVICTION REPORT AND CERTIFICATION FORM (under Act 24 of 2011 and Act 82 of 2012)

COMMONWEALTH OF PENNSYLVANIA SEXUAL MISCONDUCT/ABUSE DISCLOSURE RELEASE (under Act 168 of 2014)

REQUEST FOR DRIVER INFORMATION

CONSENT AND DIRECTION TO RELEASE DRUG AND ALCOHOL TESTING INFORMATION

PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION

The School District Of Philadelphia Driver Credential Authorization and Certification Release Form