Island Transit Facility Maintenance Position (Camano) 19758 SR 20

Phone: (360) 678-7771
Fax :
(360) 678-4353
www.islandtransit.org
info@ islandtransit.org
van pool@ islandtransit.org
19758 SR-20, Coupeville, WA 98239
October 22, 2015
Job Announcement: Facility Maintenance I (Location: Camano Island)
Dear Prospective Applicant:
Thank you for considering a Facility Maintenance position located on Camano Island .
This is a full-time position of 40 hours per week and may require some flexibility in work
schedule. The starting wage is $13 .36 per hour, following an initial training period.
The attached documents include the application packet, job requirements and
qualifications needed for the position .
How to Apply:
A complete application packet is required to be considered for the position . Do not
submit a resume without the application. Application packets must be filled out
completely and signed . Failure to complete the application packet may result in
disqualification for the position.
Mail/deliver the completed application and any supplemental documents to:
Island Transit
Facility Maintenance Position (Camano)
19758 SR 20
Coupeville, WA 98239
Position will remain Open Until Filled
Island Transit is an Equal Opportunity and M/F/DN employer.
@
Island Transit Recycles. Do you?
TITLE:
FACILITY MAINTENANCE
NON-EXEMPT
REPORTS TO:
MAINTENANCE MANAGER
SAFETY SENSITIVE
SUMMARY:
Under the direct supervision of the Facilities Coordinator, this employee is involved in
the cleaning of transit facilities and transit vehicles. This position may be part-time or
full-time based upon system requirements.
ESSENTIAL DUTIES:
Essential responsibilities of this position may include the following duties:
Clean buses and shuttle vehicles daily (inside and out).
Check and add fluids to vehicles daily.
Clean offices, facility restrooms, kitchen , and employee lounge areas.
Maintain exterior grounds at facilities ; planters, mow lawn , trash pick-up, wash windows,
and order cleaning supplies.
Clean and maintain bus stop signs and shelters.
Fuel buses on regular basis and perform bus swaps as needed.
Other duties as assigned .
DESIRABLE KNOWLEDGE, SKILLS, AND ABILITIES:
Ability to understand and follow posted work rules and procedures.
Ability to follow directions from a supervisor.
Ability to use good , sound judgment while working independently.
Work effectively with fellow employees.
Flexibility in working a schedule that varies.
Ability to report to work on time and maintain a good attendance record .
Operations knowledge of proper cleaning tools and accessories used to maintain
cleanliness of vehicles.
Possession of or ability to acquire a Washington State Class B COL with Passenger
Endorsement and Air Brake Restriction , required for fueling and bus swaps.
Basic knowledge of HVAC systems, boiler systems, automated bus wash systems,
fueling systems , water recla im systems, plumbing , electrical, pervious concrete, perform
building equipment inspection I preventative maintenance.
QUALIFICATIONS:
Requires a valid Washington State Drivers License.
Requires the ability to work effectively with other Island Transit employees.
Ability to operate small mach inery related to servicing of vehicles and facilities
maintenance as instructed .
Ability to understand and carry out instructions.
Relate to and handle various personalities and possess an awareness of human needs.
Deal with stressful situations in a calm and professional manner.
WORKING CONDITIONS, TOOLS AND EQUIPMENT:
Duties performed primarily include washing and cleaning buses in the bus wash facility
building in all types of weather. Typical bus wash facility equipment used to accomplish
job task: scrub brush ; broom ; pressure washer; mop ; and other miscellaneous cleaning
tools for facility maintenance and yard work; i.e., weed eater, riding lawn mower, ladder,
fork lift, and bucket lift.
SPECIAL REQUIREMENTS:
Employment is contingent upon successfully passing an employment medical
examination to include: drug test to be certified for the position , an employment
reference check, criminal background check; and a five year motor vehicle history
check. The Facility Maintenance I employee is considered to be a safety sensitive
position and is subject to Federal Drug and Alcohol testing regulations .
The Facility Maintenance I position is non-exempt from the Federal Labor Standards Act
(FLSA) .
AT WILL EMPLOYMENT:
I understand that if employed , I am employed AT WILL and that no contract between
JOB DESC RIPTION: FAC ILITY MAINTENANCE I
UPDATED: I 0/20/15 rg
PAGE20F9
myself and this employer is created by my completion of this application, my receiving
employment, my continued employment or my receiving benefit of employment of any
type. No promises of any form or nature have been made to me, no guarantee of any
length of employment is or shall be binding on this Employer, unless in writing. I
reserve the right to terminate my employment at any time and the Employer has the
same right at any time.
I agree to physical or other testing when such testing is reasonably necessary in
determining job related abilities or reasonable expectation of successfully performing
the job to the Employer's standards. This Summary Job Description and Position
Analysis Questionnaire does not constitute an employment agreement between the
employer and employee, and is subject to change as the needs of the employer and
requirements of the job change .
The statements contained herein reflect general details as necessary to describe the
principal functions of this job, the level of knowledge, and skill typically required and the
scope of responsibility, but should not be considered an all-inclusive listing of work
requirements . Individuals may perform other duties as assigned including work in other
functional areas to cover absences or relief, to equalize peak work periods, or otherwise
to balance the workload .
Employee
Date
Reviewed by:
Maintenance Manager
Administrative Manager
Approved by:
Executive Director
JOB DESCRIPTION: FACILITY MAINTENANCE I
UPDATED : 10/20/ 15 rg
PAGE30F9
ISLAND TRANSIT
POSITION ANALYSIS
1.
JOB TITLE: Facility Maintenance I
2.
DEPARTMENT:
Maintenance
3.
WORK HOURS:
Start Time {varies) End Time {varies) Multiple
Shifts?
Yes
4.
DESCRIBE THE MAJOR PURPOSE OR OBJECTIVE OF YOUR JOB. WHY
DOES THIS JOB EXIST?
Cleaning buses and shuttle vehicles daily - inside and out. Checking and adding
fluids to vehicles daily. Clean offices. facility restrooms . kitchen. and employee
lounge areas. Maintaining outside grounds; i.e .. planter's lawn mowing. trash
pick-up , washing of windows of entire building, and ordering of cleaning supplies.
Maintaining bus stop signs and shelters. Fuel buses on regular basis, bus swap
as needed .
5.
WHAT SKILLS AND KNOWLEDGE ARE NEEDED IN ORDER TO PERFORM
YOUR JOB?
Ability to see what needs to be cleaned and doing it well because it involves the
public. Knowledge of types of cleaning supplies needed to control the spread of
germs. Ability to operate a pressure washer and knowledge of all cleaning
supplies and tools needed for the job. Ability to operate a vacuum cleaner/carpet
cleaner. Operate small machinery and tools. Basic level of mechanical skills.
6.
WHAT SPECIFIC SKILLS OR KNOWLEDGE ARE REQUIRED? IS THERE
ANY EDUCATIONAL OR TRAINING
{INITIAL OR ONGOING) REQUIRED
TO PERFORM YOUR JOB? WHY?
Knowledge of Federal , State and local laws pertaining to the use of cleaning
supplies and location of SDS binder. Responsible for reading SDS log.
7.
WHAT TYPE OF PREVIOUS WORK EXPERIENCE IS NECESSARY TO
PERFORM YOUR JOB? WHY?
General maintenance work and previous janitorial experience.
8.
WHAT PRIOR WORK ACCOMPLISHMENTS ARE REQUIRED FOR THIS
JOB DESCRIPTION: FACILITY MAINTENANCE I
UPDATED: 10/20/15 rg
PAGE40F9
JOB? LIST ANY CERTIFICATIONS OR LICENSES REQUIRED IN ORDER TO
PERFORM YOUR JOB.
Submission of a five-year driving record, and successful passing of periodic
physical exams including drug testing according to FTA regulations.
9.
WHAT EMPLOYEE POSITIONS DO YOU DIRECTLY SUPERVISE? None
Do you have the authority to hire or fire?
Authorize Vacation?
Authorize leave of Absence
Issue Warnings?
10.
{Y}
{Y}
{Y}
{Y}
{N}
{N}
{N}
{N}
DESCRIBE THE EXTENT TO WHICH YOUR JOB REQUIRES THE USE OR
PREPARATION OF CONFIDENTIAL INFORMATION. INDICATE THE TYPE
OF INFORMATION, THE REASONS FOR DISCRETION AND THE EFFECT OF
DISCLOSURE.
None.
11.
DESCRIBE THE DUTIES AND RESPONSIBILITIES OF YOUR POSITION
THAT ARE REGULAR AND ON- GOING. INDICATE WHAT IS DONE, HOW IT
IS DONE AND WHY IT IS DONE. ESTIMATE THE ANNUAL NUMBER OF
(HOURS, WEEKS OR MONTHS) YOU SPEND ON EACH DUTY. START WITH
THE MOST TIME CONSUMING ACTIVITY.
a.
Washing buses up to 8 hours a day, cleaning building one hour a
day, and cutting grass and yard maintenance two hours a week.
*
An essential element is a job function that must be done or the mission of
the job cannot be accomplished. For example : typing is essential for a job
that requ ires all materials to be typed , but typing is not essential if handwritten work is acceptable . A driver's license is not essential if the basic
job can be accomplished without one.
Is this duty an essential element of the job?
Is th is a seasonal duty?
Annual time spent (hours, weeks, months)
b.
{Y} {N}
{Y} {N}
.12. (circle one)
Install bus stop signs. assist with shelter installation .
Is th is duty an essential element of the job?
Is this a seasonal duty?
JOB DESCRIPTION: FACILITY MAINTENANCE I
UPDATED: 10/20115 rg
{Y}
{Y}
{N}
{N}
PAGE50F9
Annual time spent
(hours, weeks, months) 12. (circle one)
c.
Ground maintenance of outside facilities. using rider mower. weed
eater. and various lawn tools. Weed flowerbeds. water flowers. pick up
trash and fallen branches. Pressure wash debris from concrete in front of
building .
Is this duty an essential element of the job?
{Y} {N}
Is this a seasonal duty?
{Y} {N}
Annual time spent (hours , weeks , months) 12 (circle one)
12.
DESCRIBE ONE OF THE
PERFORMING YOUR JOB.
MOST COMPLEX
PROBLEMS
FACED
IN
When there are body fluids to clean up from the cloth seats.
13.
WHAT KIND OF ERRORS ARE POSSIBLE ON YOUR JOB? AND, IF AN
ERROR IS MADE, WHAT EFFECT WILL IT HAVE ON YOUR JOB OR THE
JOB OF OTHERS?
Not checking fluids in buses. along with not reporting problems such as missing
screws . broken windows. flat tires. forgetting to power down the buses. resulting
in buses not able to run the next day. Forgetting to lock office doors. building , or
gates.
14.
IDENTIFY YOUR IMMEDIATE SUPERVISOR:
POSITION : MAINTENANCE MANAGER
15.
DESCRIBE THE NATURE AND EXTENT OF SUPERVISION OR GUIDANCE
RECEIVED FROM THE SUPERVISOR (BE SPECIFIC). TO WHOM DO YOU
GIVE YOUR WORK AFTER YOU COMPLETE IT?
Supervision provided as necessary.
16.
IS SUPERVISION RECEIVED FROM
IMMEDIATE SUPERVISOR?
{Y} {N}
ANYONE
OTHER
THAN
THE
POSITION : FACILITIES COORDINATOR, OPERATIONS SUPERVISOR (CAMANO)
POSITION : FACILITIES LEAD
17.
OTHER THAN YOUR SUPERVISOR DO YOU OBTAIN AUTHORITY OR
APPROVAL FROM OTHERS?
JOB DESCRIPTION: FACILITY MAINTENANCE I
UPDATED: I 0/20/ 15 rg
PAGE60F9
EXECUTIVE DIRECTOR
18.
DESCRIBE THE AMOUNT OF FREEDOM OF CHOICE ALLOWED IN
PERFORMING YOUR JOB. GIVE EXAMPLES.
Ability to establish schedule to meet job requirements within a prescribed
workday.
19.
DESCRIBE THE COMMUNICATION SKILLS REQUIRED TO PROPERLY
PERFORM YOUR JOB. CONSIDER COOPERATION, COURTESY,
PATIENCE, PERSUASION, TACT, TRUST, UNDERSTANDING, ETC. HOW
ARE THE SKILLS USED ON THE JOB?
Communication skills and teamwork to ensure vehicles are cleaned and fueled in
the required period of time.
20.
LISTS THE WORK RELATED CONTACTS THAT YOUR JOB REQUIRES YOU
TO MAKE WITH OTHERS WITHIN AND OUTSIDE THE DEPARTMENT.
INDICATE THE TYPE AND AMOUNT OF PUBLIC CONTACT REQUIRED.
a.
Purpose of Contact: Inform others about cleanliness of buses.
With whom : Maintenance, Operators , Road Support and Operations
Manager
Method: (in person) (memo) (letter) (phone)
21.
DESCRIBE THE WORK ENVIRONMENT OF YOUR JOB. CONSIDER SUCH
ELEMENTS AS FACILITIES, NOISE, INTERRUPTIONS, TEMPERATURE,
TRAVEL, PERSONAL SAFETY, ETC.
Facilities are large. jet noise. 75% of the shift requires working outside in bus
wash/fuel facil ities building in all types of weather conditions . Snow. ice. cold ,
ra in. high winds . and working various odd hours at times.
22.
LIST ANY EQUIPMENT, TOOLS, VEHICLES, AND/OR MACHINES USED TO
PERFORM YOUR JOB.
Pressure washer, vacuum cleaner carpet cleaner. lawn mower. weed eater.
small hand tools. pickup truck. portable gas power generator. and bus lift
equipment in shop. vans. fuel pumps. automated bus wash system . man lift.
23.
DESCRIBE THE AMOUNT OF FORTITUDE, STAMINA, TENACITY, AND
MINIMUM MENTAL OR COGNITIVE ABILITIES REQUIRED TO DO THE JOB
AND LIST ONE OR TWO BRIEF EXAMPLES. EXAMPLES ARE MENTAL
JOB DESCRIPTION: FACILITY MAINTENANCE I
UPDATED: I 0/20/l 5 rg
PAGE70F9
ACTIVITIES SUCH AS COMPREHENSION, ATTENTION SPAN, ALERTNESS,
READING ABILITY, MATHEMATICAL ABILITY, ETC.
Outside buses, physically repetitive work conducted in extreme conditions.
Severe weather. jet noise, etc.
a.
IS YOUR JOB INVOLVED IN EMERGENCY RESPONSE? IF YES ,
DESCRIBE MENTAL AFFECTS OF THE EMERGENCY CONDITIONS.
No. the position does not respond to emergencies.
24.
PHYSICAL DEMANDS.
a.
How much on the job time is spent in the following physical
activities? Show the amount of time by checking the appropriate blank
below.
AMOUNT OF TIME
None
Stand
Walk
Sit
Talk or Hear
Use hands to finger, handle or feel
Up to 1/3
1/3 to 2/3
2/3 & More
X
X
_x_
X
X
Climb or Balance
Stoop, Kneel , Crouch, or Crawl
Reach with Hands and Arms
Taste or Smell
X
X
X
_x_
b.
Does this job require that weight be lifted or force be exerted? If
so , how much and how often? Check the appropriate blanks below.
AMOUNT OF TIME
None
Up to 10 pounds
Up to 25 pounds
Up to 50 pounds
Up to 100 pounds
Over 100 pounds
_x_
Does th is weight have to be carried?
{Y}
c.
Up to 1/3
1/3 to 2/3
2/3 & More
X
_
_
__,x-'--_,x"--_
x
{N}
If yes, how far?
20
Feet.
Does this job have any special vision requirements? Check all that apply.
JO B DESC RIPT ION : FAC ILITY MAINTENANCE I
UPDATE D: 10/20/ 15 rg
PAG E 8 0F9
x
x
x
x
x
x
_ _
Close Vision (clear vision at 20 inches or less).
Distance Vision (clear vision at 20 feet or more).
Peripheral Vision (ability to observe an area that can be seen up
and down or to the left and right while eyes are fixed on a given
point) .
Depth Perception (three dimensional vision , ability to judge
distances and spatial relationships).
Ability to Adjust Focus (ability to adjust the eye to bring an object
into sharp focus) .
Night Vision required.
No Special Vision Requirements.
d.
Make notes on the specific job duties that require the physical
demands selected above . Describe the overall normal physical effort
required to do your job. (Lifting , bending , climbing , etc.)
Sweeping, mopping, vacuuming , dusting, cleaning windows. reaching,
bending, stooping , working on knees. pushing and pulling pressure
washer.
25.
LIST ANY OTHER COMMENTS RELATING TO YOUR JOB DUTIES AND
RESPONSIBILITIES THAT YOU FIND ARE IMPORTANT.
I, THE UNDERSIGNED, HAVE READ AND UNDERSTAND THIS JOB DESCRIPTION
QUESTIONNAIRE:
Applicant/Employee S I G N A T U R E : - - - - - - - - - - - - - - - - -
JOB DESCRIPTION: FACILITY MA INTENANCE I
UPDATED: 10/20/ 15 rg
PAGE90F9
GENERAL INFORMATION FOR APPLICANTS
EQUAL EMPLOYMENT OPPORTUNITY: All qualified persons will be considered for
employment without regard to race, color, religion, sex, national origin, age, political
affiliation, or disability status.
DRUG FREE WORKPLACE: Island Transit complies with the provisions of the DrugFree Workplace Act of 1988 and the Omnibus Employee Testing Act of 1991 mandating
ongoing drug and alcohol testing.
SMOKE FREE WORKPLACE: Smoking is permitted only in designated outdoor areas.
REASONABLE ACCOMMODATION: Island Transit will provide reasonable
accommodation to applicants with advance notice to the Administration Department.
APPLICATIONS
FILING OF APPLICATION: Applications must be completed in accordance with
directions on the front cover letter. Applicants are responsible for the truth of all
statements . Misrepresentation and incomplete or inaccurate entries may be cause for
application rejection, removal from the employment list or discharge from Island Transit
service. Applications must be received by mail or delivered by the last date of filing
applications. Applicants must notify Island Transit immediately of any address or
telephone change.
ELIGIBILITY: Candidates who have successfully completed all stages of the selection
process will be eligible for appointment in accordance with the provisions of the
personnel rules of Island Transit, which include Affirmative Action provisions. When
next to hire lists are formed, eligible candidates may remain on the list for up to six
months. Island Transit has the right to terminate a next to hire list at anytime.
EMPLOYEE BENEFITS
PAID LEAVE: Full-time Island Transit employees receive 6 paid holidays, 12 days of
sick leave, 12 days of vacation leave, and 5 floating holidays per year if employed on
January 1st of each year.
RETIREMENT: All employees of Island Transit are mandatorily included in the
Washington State Public Employees' Retirement System (PERS). Disability retirement
benefits are also available for those who qualify through PERS. Employees are eligible
to participate in the ICMA 457 Deferred Compensation Program after successful
completion of training. Employees are not covered under the Social Security Program
but are required by federal law to pay Medicare insurance. Island Transit pays for the
employer's share of Medicare.
INSURANCE PLANS: Eligible Island Transit employees and their dependents may
participate in a medical and dental insurance plan and a Accidental Death &
(G:/AAA-GENERAUApplication/AppGeneraiOps.doc) 5/1 5rg
Dismemberment Life Insurance Policy. Employees are also covered by the State
Industrial Insurance Act and may also participate in a flexible health care/dependent
care reimbursement account.
Employees may purchase through their own expense, supplemental disability, intensive
care , and cancer insurance through AFLAC .
EMPLOYMENT
HOURS OF WORK: Most Island Transit employees have a work week of between 36
and 40 hours; however, positions may require shift work, overtime, and weekend work.
SALARY INCREASES: Island Transit provides for a regular progression of salary
increases based upon longevity and satisfactory job performance.
INTRODUCTORY (PROBATIONARY PERIOD): All employees are subject to a
successful completion of an introductory period of not less than six months.
NOTE: The provisions of this General Information to Applicants do not constitute an
expressed or implied contract. Any provision contained herein may be modified and/or
revoked without notice.
(G:/AAA- GENE RAUApplication/AppGeneraiOps .doc) 5/1 5rg
EMPLOYMENT APPLICATION
ISLAND TRANSIT
19758 SR 20
COUPEVILLE, WA 98239
PHONE: (360) 678-7771
Island Transit complies with Federal requirements for a drug-free workplace.
AN EQUAL OPPORTUNITY AFFIRMATIVE ACTION EMPLOYER
IN COMPLIANCE WITH FEDERAL AND STATE EQUAL EMPLOYMENT OPPORTUNITY GUIDELINES, QUALIFIED APPLICANTS
ARE CONSIDERED FOR EMPLOYMENT WITHOUT REGARD TO RACE, CREED, COLOR, SEX, NATIONAL ORIGIN, AGE,
MARITAL STATUS OR THE PRESENCE OF A NON-JOB-RELATED CONDITION OR DISABILITY.
APPLICATION MUST BE COMPLETED IN FULL, TYPED OR IN INK, EVEN IF YOU ARE SUBMITTING A RESUME IN ADDITION
TO THIS APPLICATION . INCOMPLETE APPLICATIONS WILL NOT BE INCLUDED FOR CONSIDERATION IN THE SELECTION
PROCESS. (THE WORDS "SEE RESUME" UNDER EMPLOYMENT HISTORY ARE NOT ACCEPTABLE.)
DATE OF APPLICATION: _ _ _ _ _ _ _ _ __
:;2
TITLE OF POSITION YOU ARE APPLYING FOR: _ _ _ _ _ _ _ _ _ _ _ _ _ __
n
):
NAME:
LAST
FIRST
MIDDLE
NUMBER
STREET
APT.
STATE
ZIP CODE
SOC. SEC . NO.
ADDRESS:
CITY
PHONE:
HOME
WORK
EMAIL
MESSAGE (IF DIFFERENT)
Are you related to any current Island Transit employee?
No
Yes
lfYes:
NAME _ _ _ _ _ _ _ _ _ _ _ _ _ RELATIONSHIP_ _ _ _ _ _ _ _ __
Have you previously applied for a position with Island Transit?
No
Yes
If Yes : WHAT POSITION : - - - - - - - - - - - APPROXIMATE D A T E : - - - - - - - - Have you previously interviewed for a position with Island Transit?
No
Yes
If Yes: WHAT POSITION : - - - - - - - - - - - APPROXIMATE DATE: - - - - - - - - Have you previously been employed by Island Transit?
No
Yes
If Yes : JOB T I T L E : - - - - - - - - - - - - - - DATES: - - - - - - - - - - - - - Have you the legal right to work in the U.S.?
Yes
No
Have you been convicted, plead guilty to, or plead no contest to a felony within the last 7 years? Yes
Are you currently out on bail or awaiting trial?
Yes
No
Have you ever been fired or asked to resign?
Yes
No
Have you ever been cited or convicted of a DUI?
Yes
No
No
If "yes", give d a t e : - - - - - - - - - -
If yes, additional information may be required but would not necessarily disqualify an applicant.
Have you ever been convicted of a crime involving moral t u r p i t u d e ? - - - - - - - - - - - - - - - - - If yes, please e x p l a i n : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
(G :/AAA-GENERAUEmployee/Application/AppPage 1.doc) 5/11 rg
Page 1 of 9
3
DRIVING INFORMATION
Do you possess a valid Driver's License?
STATE : _ __
LICENSE NUMBER:
CLASS: _ __
ENDORSEMENTS :
Yes
No
EXPIRATION DATE :
DATE OF BIRTH :
(Optional unless job specifies minimum age)
Has your license ever been restricted, suspended or revoked?
No
Yes
(If yes , please explain)
Have you had any moving violations within the last five years?
No
Yes
(If yes, please explain)
Have you had any accidents within the last five years?
No
Yes
(If yes, please explain)
Driver's License Restrictions: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
(G :IAAA-GENERAL!Employee/ Application/ AppPage2 .doc) 511 1rg
Page 2 of9
EDUCATION AND TRAINING
TYPE OF
SCHOOL
HIGH SCHOOL
NAME AND
LOCATION
MAJOR
SUBJECT
CIRCLE # YRS.
COMPLETED
GRADUATE/
DEGREE
DATES
ATTENDED
9 10 11 12 GED
COLLEGE
1 2 3 4
COLLEGE
1 2 3 4
GRADUATE
SCHOOL
BUSINESS/
VOCATIONAL
OTHER RELATIVE COURSES AND TRAINING
1 2 3 4
1 2 3 4
NAME AND LOCATION OF INSTITUTION
DATES ATTENDED
TRADE, OTHER
MILITARY
ADDITIONAL LICENSES OR CERTIFICATES
STATE/DATE ISSUED
LICENSE/SERIAL NO.
LIST ANY OTHER EXPERIENCES, SKILLS OR QUALIFICATIONS
EXPIRATION DATE
WHICH YOU FEEL WOULD ESPECIALLY QUALIFY YOU FOR
THE POSITION BEING APPLIED FOR:
U.S. MILITARY BACKGROUND
I
BRANCH OF S E R V I C E : - - - - - - - - DATE IN: _ _ _ _ _ _ _ DATE O U T : - - - - - - -
(G:/AAA- GENERAL!Employee/Application/AppPage3. doc) 5/11 rg
Page 3 of 9
EMPLOYMENT HISTORY
List and describe your work record for the last ten years. Begin with your most recent experience. List each position within a company
separately. Include periods of unemployment or self-employment. Attach additional sheets if more space is needed.
Island Transit will provide reasonable accommodation to applicants with disabilities with advance notice to the Human Resources
Department.
It is the policy of Island Transit, as part of the selection process, to contact your former employers for employment-related reference
information. We will not at this time contact your present employer unless you authorize us to do so. If you do not authorize us to
contact all but your present employer, you may be disqualified from consideration for the position.
NOTE : IN COMPLIANCE WITH THE COMMERCIAL MOTOR VEHICLE SAFETY ACT OF 1986, PLEASE INCLUDE ANY
PREVIOUS EMPLOYMENT AS A COMMERCIAL DRIVER FOR AT LEAST THE PREVIOUS TEN (10) YEAR PERIOD.
FIRM NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ POSITION: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ADDRESS:
DATES EMPLOYED: From: _ _ _ _ _ To: _ _ __
CITY/STATE/ZIP:----------------------------------SUPERVISOR/TITLE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PHONE:---------------------------------------REASONFORLEAVING: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
WAS YOUR REASON FOR LEAVING VOLUNTARY?:. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
JOB DUTIES: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
FIRM NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ POSITION: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ADDRESS:
DATES EMPLOYED: From: _ _ _ _ _To: _ _ __
CITY/STATE/ZIP:----------------------------------SUPERVISOR/TITLE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PHONE:--------------------------------------REASONFORLEAVING: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
WAS YOUR REASON FOR LEAVING VOLUNTARY?: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
JOB DUTIES: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
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Page 4 of 9
FIRM NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ,POSITION: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ADDRESS:
DATES EMPLOYED: From: _ _ _ _ _To: _ _ __
CITY/STATE/ZIP:------------------------------------SUPERVISOR/TITLE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PHONE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
REASON FOR LEAVING: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
WAS YOUR REASON FOR LEAVING VOLUNTARY?: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
JOB DUTIES: _____________________________________________________________________
FIRM NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ POSITION: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ADDRESS:
DATES EMPLOYED: From: ________ To: _ _ __
CITY/STATE/ZIP:----------------------------------SUPERVISOR/TITLE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PHONE:---------------------------------------REASONFORLEAVING: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
WAS YOUR REASON FOR LEAVING VOLUNTARY?: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
JOB DUTIES: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
FIRM NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ POSITION: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ADDRESS:
DATES EMPLOYED: From: ________To: _ _ __
CITY/STATE/ZIP:-----------------------------------SUPERVISOR/TITLE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PHONE:---------------------------------------REASONFORLEAVING: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
WAS YOUR REASON FOR LEAVING VOLUNTARY?: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
JOB DUTIES: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
(G:IAAA-GENERAUEmployee/Application/AppPage5.doc) 5/11 rg
Page 5 of 9
PERSONAL REFERENCES: (NOT FORMER EMPLOYERS OR RELATIVES)
1. __________________________________________
TELEPHONE: _______________________
2. __________________________________________
TELEPHONE : _______________________
3. __________________________________________
TELEPHONE: _______________________
ANSWER THE FOLLOWING QUESTIONS WITH A YES OR NO ANSWER:
1) CAN YOU PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB FOR WHICH YOU ARE APPLYING? YES
2) DO YOU CURRENTLY USE ILLEGAL DRUGS?
YES
NO
NO ___
3) DO YOU HAVE A RELIABLE FORM OF TRANSPORTATION TO AND FROM WORK? YES ___ NO ___
4) ARE YOU AVAILABLE TO WORK A WIDE VARIETY OF HOURS AND SHIFTS DURING THE WEEK? YES _ _ NO_ _
THE FACTS SET FORTH IN MY APPLICATION FOR EMPLOYMENT ARE TRUE AND CORRECT. I UNDERSTAND THAT
MISREPRESENTATION IN MY ANSWERS OR STATEMENTS WILL VOID MY APPLICATION , OR IF EMPLOYED WILL BE
SUFFICIENT CAUSE FOR DISMISSAL.
I FURTHER AGREE THAT FALSIFICATION OR WITHHOLDING OF PERTINENT INFORMATION GIVEN IN MY APPLICATION OR
INTERVIEW (S) WILL BE GROUNDS FOR NON-CONSIDERATION , OR IF EMPLOYED, WILL BE CAUSE FOR DISMISSAL.
Signature ___________________________________ Date __________________________
Initial if we may also contact your present employer ____
(G :/AAA-GENERAUEmployee/Application/AppPage6.doc) 5/11 rg
Page 6 of 9
Disclosure Statement
Pursuant to the requirements of RCW 43.43.830-840, we must ask you to complete the
following disclosure statement. This information will be kept confidential.
Have you ever been convicted of any of the following crimes against persons:
YES
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Aggravated, first or second degree murder
First or second degree kidnapping
First, second or third degree assault
First, second or third degree rape
First, second or third degree statutory rape
First or second degree robbery
First degree arson
First degree burglary
First or second degree manslaughter
First or second degree extortion
Indecent liberties
Incest
Vehicular homicide
First degree promoting prostitution
Communication with a minor
Unlawful imprisonment
Simple assault
First or second degree custodial interference
Malicious harassment
First, second or third degree child molestation
First, second or third degree sexual misconduct with a minor
First or second degree rape of a child
Patronizing a juvenile prostitute
Child abandonment
Promoting pornography
Selling or distributing erotic material to a minor
Custodial assault
Violation of a child abuse restraining order
Child buying or selling
Felony indecent exposure
Sexual exploitation of minors
First or second degree criminal mistreatment
Or any of these crimes as they have been renamed
If your answer is "yes" to any of the above, please describe and provide the date(s) of
the conviction(s) and the sentence(s) imposed.
(G:/AAA-GENERAUEmployee/Application/AppPage7 .doc) 5/11 rg
Page 7 of 9
Has a (a) dependency action , (b) domestic relations proceeding , or (c) disciplinary
board fin al decision found you to have sexually assaulted or exploited a minor, or to
have phys ica lly abused or sexually abused a minor? ( ) YES ( ) NO
If your answer is "yes", please described and provide the date(s) of the finding(s) and
penalty (ies) imposed.
Have you ever tested positive or refused to test on any pre-employment drug or alcohol
tests?
If your answer is "yes", please describe and provide the date(s) of the finding(s) and
penalty (ies) imposed.
We may request your fingerprints to obtain from the Washington State Patrol criminal
identification system a report of your record of criminal convictions for offenses against
persons, civil adjudications of child abuse , and disciplinary board final decisions. AS
PART OF THE HIRING PROCESS, A SATISFACTORY REPORT MUST BE
RECEIVED.
You will be notified of the State Patrol's response within ten days after we receive the
report. We will make a copy of the report available to you upon your request.
UNDER PENALTY OF PERJURY, I certify that the above information is true, correct
and complete.
I understand that if I am hired, I can be discharged for any
misrepresentation or omission in the above statement.
Signature
Date
Name (print)
(G:/AAA- GENERAU Employee/Applicati on/AppPage8.doc) 5/11 rg
Page 8 of 9
As a recipient of federal funds , Island Transit must compile statistical data on the sex, minority and disability
status of job applicants. If you wish to provide this statistical information, please indicate below. This data will
be removed from the applications and entered only on an applicant flow log . If you do not wish to provide this
information, your status will be summarized into an "unknown" category and will not jeopardize you as a
prospective employee.
Island Transit is an equal opportunity employer and encourages all qualified persons, including disabled and
Vietnam era veterans , woman , racial and ethnic minorities, people with disabilities, and persons over 40 years
of age, to apply. We ask that you voluntarily answer the following questions and return this document with your
application. This information will be treated as confidential and is only available to authorized personnel and
the hiring authority. Persons with disabilities needing assistance in the application process, or those needing
this job announcement in an alternative format may call (360) 678-7771 .
POSITION FOR WHICH YOU ARE APPLYING : - - - - - - - - - - - DATE OF THIS APPLICATION :
NAME :
LAST NAME
FIRST NAME
M.l.
STATISTICAL INFORMATION
SEX
1
2
AGE 40 OR OLDER
1
MALE
FEMALE
2
YES
NO
Do you have a physical, sensory, or mental condition that substantially limits any of your major life functions ,
such as working , caring for yourself, walking , doing things with your hands, seeing , hearing, speaking and
learning?
Yes _ _ No
Have you ever been on active duty in the US Armed Services?
Vietnam Era Veteran
Disabled Veteran
Yes
Yes
No
No
Percent of Disability _ _%
What race or culture do you consider yourself? Please check only one group. If you are
more than one race please check "other."
Black/African American
White/Caucasian
Asian or Pacific Islander
--Indian/Native American-- Hispanic/Spanish/Latino(a) _ _Other (please indicate race/culture(s)
and list in order of preference for Affirmative Action purposes.)
HOW DID YOU FIND OUT ABOUT THE POSITION FOR WHICH YOU ARE APPLYING?
1
2
3
NEWSPAPER
ANNOUNCEMENT
WALK-IN
Signature:
4
5
6
FRIEND
EMPLOYMENT SECURITY
OTHER _ _ _ _ _ __
--------------------------------------- Date:
(G:/AAA-GENERAUEmployee/Application/AppPage9.doc) 5/1 Osb
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