1st Class Transit Monitor Application CREOLE

Fòmilè (Form)
Non (Name)*

Premye NonSiyati/Non Fanmi
Nimewo Sekirite Sosyal (Social Security Number)*
no spaces or dashes
Dat Jodi a (Today's Date)

MwaJouAne
Dat
Nimewo Telefòn (Phone Number)*
Tanpri antre yon nimewo telefòn valid.Format: (000) 000-0000.
Imèl (Email)
example@example.com
Adrès (Address)*

Adrès Ri

Adrès Ri Liy 2

VilEta / Pwovens

Kòd Postal
Konbyen tan ou rete la (Time Living There)
mm/yyyy - mm/yyyy
Kontak Ijans (Emergency Contact)*
Name
Nimewo Telefòn Kontak Ijans (Emergency Contact Phone Number)*
Tanpri antre yon nimewo telefòn valid.Format: (000) 000-0000.
Wi (Yes)Non (No)
Wi (Yes)Non (No)
Dat ou ka kòmanse (Date you can start)

MwaJouAne
Dat
Wi (Yes)Non (No)
Peyi Sitwayen (Country of Citizenship)
If you do not have US Citizenship, please type the country you are still a current citizen of.
Peyi Nesans (Birth Country)
Which Country were you born in?
Vil Nesans (City of Birth)
Which City were you born in?
Wi (Yes)Non (No)
Nimewo ID Eta (State ID Number)*
Eta (State)*
Dat Ekspirasyon (Expiration Date)*

MwaJouAne
Dat
Tip Lisans Chofè (Estanda oswa CDL) (Driver's License Type (Standard or CDL))
Edikasyon Pi Wo (Highest Education)
Dat Fini (Date Completed)

MwaJouAne
Dat
Wotè (Height)*
Pwa (Weight)*
Koulè Cheve (Hair Color)*
Koulè Je (Eye Color)*
Ane Machin (Car Year)*
Nimewo VIN (VIN Number)*
Mak Machin (Car Make)*
Modèl Machin (Car Model)*
Kilometeraj (Mileage)
Siyati (Signature)*
Dat (Date)

MwaJouAne
Dat

RAPÒ ARESTASYON/KONDANASYON AK FÒMILÈ SÈTIFIKASYON (dapre Lwa 24 de 2011 ak Lwa 82 de 2012) (ARREST/CONVICTION REPORT AND CERTIFICATION FORM (under Act 24 of 2011 and Act 82 of 2012))
Non (Name)

Premye NonSiyati/Non Fanmi
Dat Nesans (Date of Birth)*

MwaJouAne
Dat
Lòt non ou te itilize (Other Names by which you have been identified)
Klike Isit la (Click Here)(vid) ((blank))
Pou chak arestasyon oswa kondanasyon pou nenpòt Ofans ki dwe Rapòte, presize nan espas anba a (oswa sou pyès anekse siplemantè si sa nesesè) ofans yo te arete w oswa kondane w pou li a, dat ak kote arestasyon an ak/oswa kondanasyon an, nimewo dosye a, ak tribinal ki aplike a. (For each arrest for or conviction of any....)
Klike Isit la (Click Here)(vid) ((blank))
Lè m siyen fòmilè sa a, mwen sètifye anba penalite lalwa ke deklarasyon yo nan fòmilè sa a vrè, kòrèk ak konplè. Mwen konprann ke fo deklarasyon ladan l, san limit, nenpòt echèk pou rapòte nenpòt arestasyon oswa kondanasyon pou yon Ofans ki dwe Rapòte, ap soumèt mwen a pourswit kriminèl anba 18 Pa.C.S. §4904, ki gen rapò ak fo deklarasyon san sèman bay otorite yo.*
Dat Jodi a (Today's Date)

MwaJouAne
Dat

COMMONWEALTH OF PENNSYLVANIA DIVILGASYON MOVE KONDWIT SEKSYÈL/ABI (dapre Lwa 168 de 2014) (COMMONWEALTH OF PENNSYLVANIA SEXUAL MISCONDUCT/ABUSE DISCLOSURE RELEASE (under Act 168 of 2014))

Antite lekòl k ap anboche oswa kontraktè endepandan soumèt fòmilè sa a bay TOUT anplwayè aktyèl yo ak ansyen anplwayè ki te antite lekòl e/oswa kote aplikan an te gen kontak dirèk ak timoun)
Tcheke isit la si ou pa t janm travay nan yon konpayi kote ou te gen kontak dirèk ak timoun kòm travay prensipal ou (Check here if you never were employed with a company in which you dealt directly with children as your main job)
Non (Name)

Premye NonSiyati/Non Fanmi
Nenpòt ansyen non aplikan an te itilize, si pa gen lòt non kite vid (Any former names by which the applicant has been identified, if no other aliases leave blank)
Dat Nesans (Date of Birth)

MwaJouAne
Dat
4 dènye chif Nimewo Sekirite Sosyal Aplikan an: (Last 4 digits of Applicant's Social Security Number:)*
Wi (Yes)Non (No)
Wi (Yes)Non (No)
Wi (Yes)Non (No)
Lè m siyen fòmilè sa a, mwen sètifye anba penalite lalwa ke deklarasyon yo nan fòmilè sa a kòrèk, konplè, ak vrè dapre sa m konnen pi byen. Mwen konprann ke fo deklarasyon ladan l, san limit, nenpòt echèk volontè pou divilge enfòmasyon ki obligatwa, ap soumèt mwen a pourswit kriminèl anba 18 Pa.C.S. § 4904 (ki gen rapò ak fo deklarasyon san sèman bay otorite yo) ak disiplin jiska, ak enkli, revokasyon oswa refi travay, epi ka soumèt mwen a penalite sivil ak aksyon disiplinè anba Lwa Disiplin Edikatè a. Mwen otorize tou anplwayè ki nonmen anwo a pou lage bay antite ki endike nan paj 3 la, enfòmasyon yo mande nan SEKSYON 2 fòmilè sa a ak tout dosye ki gen rapò. Mwen lage, renonsye, ak decharge anplwayè ki nonmen anwo a de tout responsablite nenpòt kalite ki ka soti nan divilgasyon oswa liberasyon dosye sa yo. Mwen konprann ke vandè tyès pati ka itilize pou trete revizyon istwa anvan travay Lwa 168 sa a.*
Dat Jodi a (Todays Date)

MwaJouAne
Dat
- Non anplwayè (Name of employer)
- Adrès (Address)
  
  Adrès Ri
  
  Adrès Ri Liy 2
  
  VilEta / Pwovens
  
  Kòd Postal
- Nimewo Telefòn (Phone Number)
  Tanpri antre yon nimewo telefòn valid.Format: (000) 000-0000.
- Nimewo Faks (Fax Number)
  Tanpri antre yon nimewo telefòn valid.Format: (000) 000-0000.
- Imèl (Email)
  example@example.com
- Tit Moun Kontak (Contact Person Title)
- Non Moun Kontak (Contact Person Name)
- Dat apwoksimatif travay ak antite ki endike anwo a (Approximates dates of employment with the entity listed above)
- Pozisyon ou te okipe nan antite a (Position(s) held with the entity)

DEMANN POU ENFÒMASYON CHOFÈ (REQUEST FOR DRIVER INFORMATION)

Depatman Transpò Pennsylvania (Fòmilè demann istwa chofè)
Non (Name)

Premye NonSiyati/Non Fanmi
Adrès (Address)

Adrès Ri

Adrès Ri Liy 2

VilEta / Pwovens

Kòd Postal
Nimewo Telefòn
Tanpri antre yon nimewo telefòn valid.Format: (000) 000-0000.
Dat Nesans (Date Of Birth)

MwaJouAne
Dat
Nimewo Lisans Chofè (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.
Siyati (Signature)*
Dat

MwaJouAne
Dat
Klike Swivan pou ale nan paj swivan an (Click Next To go to the next page)

KONSANTMAN AK DIREKSYON POU LAGE ENFÒMASYON TÈS DWÒG AK ALKÒL (CONSENT AND DIRECTION TO RELEASE DRUG AND ALCOHOL TESTING INFORMATION)
Moun sa a ("Enskri") enskri nan Konsòsyòm nan (1st Class Transit LLC). Dapre Konsantman ki siyen anba a, Konsòsyòm nan (1st Class Transit LLC) dwe bay ALC Schools, LLC ("ALC") tip rezilta tès ak enfòmasyon ki endike anba a pou Enskri ki nonmen sou fòmilè sa a. Enskri ki nonmen la a otorize ak dirije Konsòsyòm nan (1st Class Transit LLC) ki nonmen la a, epi Konsòsyòm nan (1st Class Transit LLC) dakò, nan 24 èdtan apre rezilta/enfòmasyon yo disponib, pou lage ak bay pa imèl oswa faks tout rezilta ak enfòmasyon ki gen rapò ak tès dwòg ak/oswa alkòl ki fèt sou nenpòt echantiyon Enskri a bay, enkli tout dosye, tablo, rapò, nòt, dokiman, korespondans ak estati enskripsyon nan pwogram tès dwòg ak alkòl ki dekri anwo a bay adrès ak nimewo ALC yo bay Konsòsyòm nan (1st Class Transit LLC).
Konsòsyòm nan (1st Class Transit LLC) otorize tou epi dirije pou lage epi dakò pou lage ak bay sa ki annapre yo bay ALC: 1. Fòmilè sa a kòm konfimasyon enskripsyon Enskri a nan pwogram Konsòsyòm nan (1st Class Transit LLC); 2. Kopi règ ak pwosedi Konsòsyòm nan (1st Class Transit LLC) (sof si deja nan dosye ALC); 3. Alèt imèl (nan 24 èdtan) lè Enskri a retire nan pwogram nan; epi 4. Konfimasyon ke pwogram nan ap bay ALC rapò anyèl sou nimewo tès owaza.
Non (Name)

Premye NonSiyati/Non Fanmi
4 dènye chif Nimewo Sekirite Sosyal (Last 4 of Social Security Number)
Siyati (Signature)*
Dat

MwaJouAne
Dat

SÈTIFIKASYON ISTWA ABI TIMOUN PENNSYLVANIA (PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION)
Non (Name)

Premye NonSiyati/Non Fanmi
Dezyèm Non
If you do not have a middle name type NONE or NMN
Nimewo Sekirite Sosyal (Social Security Number)
Format XXX - XX - XXXX
Gason (Male)Fi (Female)Pa rapòte (Not reported)
Dat Nesans (Date of Birth)

MwaJouAne
Dat
Laj Aktyèl (Current Age)
Adrès (Address)

Adrès Ri

Adrès Ri Liy 2

VilEta / Pwovens

Kòd Postal
Konte (County)
Nimewo Telefòn (Phone Number)
Tanpri antre yon nimewo telefòn valid.Format: (000) 000-0000.
- Ansyen Non 1 (Previous Name 1)
  
  Premye NonSiyati/Non Fanmi
- Ansyen Non 2 (Previous Name 2)
  
  Premye NonSiyati/Non Fanmi
- Ansyen Adrès 1 (Previous Address 1)*
  
  Adrès Ri
  
  Adrès Ri Liy 2
  
  VilEta / Pwovens
  
  Kòd Postal
- Ansyen Adrès 2 (Previous Address 2)
  
  Adrès Ri
  
  Adrès Ri Liy 2
  
  VilEta / Pwovens
  
  Kòd Postal
- Ansyen Adrès 3 (Previous 3)
  
  Adrès Ri
  
  Adrès Ri Liy 2
  
  VilEta / Pwovens
  
  Kòd Postal
- Non Papa (Father Name)*
  First, Middle, Last
- Laj Aktyèl Papa OSWA Laj li te Mouri (Father Current Age OR the Age he died)*
- Sèks Papa (Father Gender)
  Type: Male, Female, or They
- Non Manman (Mother Name)*
  First, Middle, Last
- Laj Aktyèl Manman OSWA Laj li te Mouri (Mother Current Age OR the Age she died)*
- Sèks Manman (Mother Gender)
  Type: Male, Female, or They
- Non Konjwen (Spouse Name)
  First, Middle, Last
- Laj Aktyèl Konjwen OSWA Laj Konjwen te Mouri (Spouse Current Age OR the Age Spouse died)
- Sèks Konjwen (Spouse Gender)
  Type: Male, Female, or They
- Non Frè/Sè 1 (Sibling 1 Name)
  First, Middle, Last
- Laj Aktyèl Frè/Sè 1 OSWA Laj Frè/Sè 1 te Mouri (Sibling 1 Current Age OR the Age Sibling 1 died)
- Sèks Frè/Sè 1 (Sibling 1 Gender)
  Type: Male, Female, or They
- Non Frè/Sè 2 (Sibling 2 Name)
  First, Middle, Last
- Laj Aktyèl Frè/Sè 2 OSWA Laj Frè/Sè 2 te Mouri (Sibling 2 Current Age OR the Age Sibling 2 died)
- Sèks Frè/Sè 2 (Sibling 2 Gender)
  Type: Male, Female, or They
- Non Frè/Sè 3 (Sibling 3 Name)
  First, Middle, Last
- Laj Aktyèl Frè/Sè 3 OSWA Laj Frè/Sè 3 te Mouri (Sibling 3 Current Age OR the Age Sibling 3 died)
- Sèks Frè/Sè 3 (Sibling 3 Gender)
  Type: Male, Female, or They
- Non Pitit 1 (Child 1 Name)
  First, Middle, Last
- Laj Aktyèl Pitit 1 OSWA Laj Pitit 1 te Mouri (Child 1 Current Age OR the Age Child 1 died)
- Sèks Pitit 1 (Child 1 Gender)
  Type: Male, Female, or They
- Non Pitit 2 (Child 2 Name)
  First, Middle, Last
- Laj Aktyèl Pitit 2 OSWA Laj Pitit 2 te Mouri (Child 2 Current Age OR the Age Child 2 died)
- Sèks Pitit 2 (Child 2 Gender)
  Type: Male, Female, or They
- Non Pitit 3 (Child 3 Name)
  First, Middle, Last
- Laj Aktyèl Pitit 3 OSWA Laj Pitit 3 te Mouri (Child 3 Current Age OR the Age Child 3 died)
- Sèks Pitit 3 (Child 3 Gender)
  Type: Male, Female, or They
- Non Pitit 4 (Child 4 Name)
  First, Middle, Last
- Laj Aktyèl Pitit 4 OSWA Laj Pitit 4 te Mouri (Child 4 Current Age OR the Age Child 4 died)
- Sèks Pitit 4 (Child 4 Gender)
  Type: Male, Female, or They
- Siyati (Signature)*
- Dat
  
  MwaJouAne
  Dat

Fòmilè Otorizasyon ak Sètifikasyon Kalifikasyon Chofè Distri Lekòl Philadelphia (The School District Of Philadelphia Driver Credential Authorization and Certification Release Form)
Non (Name)

Premye NonSiyati/Non Fanmi
Nimewo Lisans Chofè (Driver's License Number)
8 digits
Eta Lisans Chofè te Emèt (State Driver's License Issued)
Dat Nesans (Date Of Birth)

MwaJouAne
Dat
Klike Swivan pou ale nan etap swivan an - telechaje ID ou ak pran yon foto tèt ou. (Click Next To Go to the next step - uploading your ID and taking a selfie picture.)

TELECHAJMAN (UPLOADS)

Tanpri netwaye kamera ou anvan ou pran foto
Pran Foto Kat Idantifikasyon (Take Photo of Identification Card)
Pran Foto Anrejistreman Machin (Take Photo of Vehicle Registration)
Pran Foto Kat Asirans Machin (Take Photo of Vehicle Insurance Card)
Pran Foto Etikèt Enspeksyon sou devan machin nan (Take Photo of Inspection Stickers on the front of the car)
Pran Foto Devan Machin nan (Take Photo of Front of Vehicle)
Pran Foto Dèyè Machin nan (Take Photo of Back of Vehicle)
Pran Foto Bò Chofè Machin nan (Take Photo of Driver Side of Vehicle)
Pran Foto Bò Pasaje Machin nan (Take Photo of Passenger Side of Vehicle)
- Telechaje Foto Kat Idantifikasyon (Upload Photo of Identification Card)
- Telechaje Foto Asirans Machin (Upload Photo of Vehicle Insurance)
- Telechaje Foto Anrejistreman Machin (Upload Photo of Vehicle Registration)
- Telechaje Foto Etikèt Enspeksyon sou devan machin nan (Upload Photo of Inspection Stickers on the front of the car)
- Telechaje Foto Devan Machin nan (Upload Photo of front of Vehicle)
- Telechaje Foto Dèyè Machin nan (Upload Photo of back of Vehicle)
- Telechaje Foto Bò Chofè Machin nan (Upload Photo of Driver Side of Vehicle)
- Telechaje Foto Bò Pasaje Machin nan (Upload Photo of Passenger Side of Vehicle)

Foto Tèt Ou (Selfie) (Selfie Picture)

Netwaye Devan kamera ou
Pran yon Selfie, Asire w vire kamera a sot dèyè pou devan (Take a Selfie, Make sure to flip camera from back to front)
Oswa Telechaje yon Selfie isit la (Or Upload a Selfie here)

Kat Vaksinasyon Covid-19 (Covid-19 Vaccination Card)

Si ou gen Kat Vaksinasyon COVID-19 ou, ou pral pran yon foto oswa telechaje l isit la
Pran Foto Kat Vaksinasyon Covid-19 ou (Take Photo of your Covid-19 Vaccination Card)
Telechaje Foto Kat Vaksinasyon Covid-19 ou (Upload Photo of your Covid-19 Vaccination Card)
Should be Empty:

Fòmilè (Form)

RAPÒ ARESTASYON/KONDANASYON AK FÒMILÈ SÈTIFIKASYON (dapre Lwa 24 de 2011 ak Lwa 82 de 2012) (ARREST/CONVICTION REPORT AND CERTIFICATION FORM (under Act 24 of 2011 and Act 82 of 2012))

COMMONWEALTH OF PENNSYLVANIA DIVILGASYON MOVE KONDWIT SEKSYÈL/ABI (dapre Lwa 168 de 2014) (COMMONWEALTH OF PENNSYLVANIA SEXUAL MISCONDUCT/ABUSE DISCLOSURE RELEASE (under Act 168 of 2014))

DEMANN POU ENFÒMASYON CHOFÈ (REQUEST FOR DRIVER INFORMATION)

Klike Swivan pou ale nan paj swivan an (Click Next To go to the next page)

KONSANTMAN AK DIREKSYON POU LAGE ENFÒMASYON TÈS DWÒG AK ALKÒL (CONSENT AND DIRECTION TO RELEASE DRUG AND ALCOHOL TESTING INFORMATION)

SÈTIFIKASYON ISTWA ABI TIMOUN PENNSYLVANIA (PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION)

Fòmilè Otorizasyon ak Sètifikasyon Kalifikasyon Chofè Distri Lekòl Philadelphia (The School District Of Philadelphia Driver Credential Authorization and Certification Release Form)

Klike Swivan pou ale nan etap swivan an - telechaje ID ou ak pran yon foto tèt ou. (Click Next To Go to the next step - uploading your ID and taking a selfie picture.)

TELECHAJMAN (UPLOADS)

Foto Tèt Ou (Selfie) (Selfie Picture)

Kat Vaksinasyon Covid-19 (Covid-19 Vaccination Card)