Print Form

INSTRUCTIONS FOR COMPLETING

EMPLOYMENT APPLICATION

1. Complete all sections of the Employment Application thoroughly and accurately.

2. You must include all your employment history for the past ten years (if applicable) or
above. If you need more space to complete your employment history, use the
Supplemental Application form that has been included in your application package.
The supplemental application must be used to complete the additional employment
information.
3. If you have a conviction, violation or infraction including traffic related matters,
please provide an explanation of the conviction, violation or infraction on the sheet
that has been provided in the package.
IN ANSWERING THIS QUESTION, DO NOT DISCLOSE ANY CONVICTION
THAT (i) IS A SEALED CONVICTION OR (ii) THAT IS CLASSIFIED AS A
YOUTHFUL OFFENDER ADJUDICATION.
4. Failure to follow these instructions will result in a delay in processing your
application.
5. After your interview, if you are selected to continue in the process, the next step will
be a background investigation of the information that you have provided on your
Employment Application.

Page 1 of 27

Employment Office

MTA LONG ISLAND RAIL ROAD

EMPLOYMENT APPLICATION

LAST NAME (PLEASE PRINT)

FIRST NAME

(M)

DATE

Company Policy prohibits discrimination on the basis of race, sex, sexual orientation, color, age, national origin, creed or disability.

Page 2 of 27

EMPLOYMENT APPLICATION
Failure to answer every question could result in a delay of your application.

PERSONAL INFORMATION
LAST NAME (please print)

FIRST

MIDDLE

HOME (STREET) ADDRESS

SS# (Last 4 Digits Only)

CITY OR TOWN

STATE

ZIP CODE

MAILING ADDRESS, if different

HOME TELEPHONE NO.

PAGER NO.

CELL PHONE NO.

FAX NO.

E-MAIL ADDRESS

EDUCATIONAL INFORMATION
DO YOU HAVE A:
HIGH SCHOOL DIPLOMA

OTHER TRAINING (including military)

G.E.D.

NONE

WHERE DID YOU OBTAIN YOU H.S. DIPLOMA OR G.E.D.?

School:

COLLEGE (list all attended)

Address:

MAJOR SUBJECT

City:

DID YOU RECEIVE A:

DEGREE

State:

TYPE:

IF NONE, #
CREDITS
COMPLETED:

TYPE:

IF NONE, #
CREDITS
COMPLETED:

TYPE:

IF NONE, #
CREDITS
COMPLETED:

CERTIFICATE

NEITHER
ADDRESS

COLLEGE (list all attended)

MAJOR SUBJECT

DID YOU RECEIVE A:

DEGREE

CERTIFICATE

NEITHER
ADDRESS

COLLEGE (list all attended)

MAJOR SUBJECT

DID YOU RECEIVE A:

DEGREE

CERTIFICATE

NEITHER
ADDRESS

ARE YOU PRESENTLY ATTENDING SCHOOL PART-TIME?

YES
NO

IF YES, EXPLAIN

ARE YOU PLANNING TO ATTEND SCHOOL?

YES
NO

BUSINESS AND PROFESSIONAL MEMBERSHIPS, LICENSES AND/OR CERTIFICATES RELATED TO THIS POSITION
NAME OF ORGANIZATION

DATES

CITY

STATE

OFFICES HELD, IF ANY

NAME OF ORGANIZATION

DATES

CITY

STATE

OFFICES HELD, IF ANY

Company Policy prohibits discrimination on the basis of race, sex, sexual orientation, color, age, national origin, creed or disability.

Page 3 of 27

EMPLOYMENT INFORMATION (List all employers for the last 10 years, starting with most recent. Give full addresses including non-US
employers use Supplemental Forms, if necessary).
NAME OF EMPLOYER

REASON FOR LEAVING

EMPLOYMENT DATES(Month/Year)
FROM:
TO:

ADDRESS

SUPERVISORS NAME/TITLE

LAST SALARY

COMPANY TELEPHONE NO.

YOUR TITLE

HR TELEPHONE NO.

HR NAME/TITLE

NAME OF EMPLOYER

REASON FOR LEAVING

EMPLOYMENT DATES(Month/Year)
FROM:
TO:

ADDRESS

SUPERVISORS NAME/TITLE

LAST SALARY

COMPANY TELEPHONE NO.

YOUR TITLE

HR TELEPHONE NO.

HR NAME/TITLE

NAME OF EMPLOYER

REASON FOR LEAVING

EMPLOYMENT DATES(Month/Year)
FROM:
TO:

ADDRESS

SUPERVISORS NAME/TITLE

LAST SALARY

COMPANY TELEPHONE NO.

YOUR TITLE

HR TELEPHONE NO.

HR NAME/TITLE

NAME OF EMPLOYER

REASON FOR LEAVING

EMPLOYMENT DATES(Month/Year)
FROM:
TO:

ADDRESS

SUPERVISORS NAME/TITLE

LAST SALARY

COMPANY TELEPHONE NO.

YOUR TITLE

HR TELEPHONE NO.

HR NAME/TITLE

CITY

STATE

ZIP

HR ADDRESS (If Different)

DESCRIBE DUTIES AND RESPONSIBILITIES:

CITY

STATE

ZIP

HR ADDRESS (If Different)

DESCRIBE DUTIES AND RESPONSIBILITIES:

CITY

STATE

ZIP

HR ADDRESS (If Different)

DESCRIBE DUTIES AND RESPONSIBILITIES:

CITY

STATE

HR ADDRESS (If Different)

ZIP

DESCRIBE DUTIES AND RESPONSIBILITIES:

Company Policy prohibits discrimination on the basis of race, sex, sexual orientation, color, age, national origin, creed or disability.

Page 4 of 27

HAVE YOU EVER FILLED OUT AN APPLICATION FOR

EMPLOYMENT WITH THE LONG ISLAND RAIL ROAD?
IF YES, WHAT POSITION?

YES

NO
WHAT WAS THE RESULT?

DO YOU HAVE A VALID DRIVERS LICENSE?

YES
NO

HAVE YOU EVER BEEN EMPLOYED BY

THE LONG ISLAND RAIL ROAD?

YES
NO

YEAR

STATE:

IF YES, WHAT POSITION?

REASON FOR LEAVING?

HAVE YOU EVER BEEN EMPLOYED BY

ANY OTHER RAIL ROAD OR MTA AGENCY?

YEAR

YES
NO

DO YOU HAVE ANY OTHER STATE OR FEDERAL

LICENSES (INCLUDING TRADE OR OCCUPATION)?
IF YES, INDICATE TYPE:

YES

IF YES, WHAT RAIL ROAD OR AGENCY?

POSITION

YEAR

NO

SUPPLEMENTARY INFORMATION
HAVE YOU EVER SERVED IN THE U.S. ARMED FORCES?
YES

BRANCH OF SERVICE

RANK AT DISCHARGE

NO

IF YES, PLESE INDICATE YOUR STATUS BELOW:

I AM CURRENTLY ACTIVE DUTY/RESERVES IN THE U.S. ARMED
FORCES.
I AM A VETERAN WITH HONORABLE DISCHARGE AND A DD-214.
I AM A VETERAN WITH OTHER THAN HONORABLE DISCHARGE.

DATE OF SERVICE (MONTH/YEAR)

TO

FROM

ARE YOU OR HAVE YOU EVER BEEN A MEMBER OF A PUBLICLY-FUNDED PENSION SYSTEM IN NYC OR NYS?
IF YES, PLEASE PROVIDE NAME OF SYSTEM AND INDICATE MEMBERSHIP TIER IF APPLICABLE:
IF YOU ANSWERED YES, ARE YOU CURRENTLY RECEIVING RETIREMENT BENEFITS FROM THIS PENSION PLAN?

HAVE YOU EVER BEEN CONVICTED OF A CRIME, VIOLATION

OR INFRACTION? (Including Traffic Convictions) IN ANSWERING THIS
QUESTION, DO NOT DISCLOSE ANY CONVICTION THAT (i) IS A
SEALED CONVICTION OR (ii) THAT IS CLASSIFIED AS A YOUTHFUL
OFFENDER ADJUDICATION.

YES

DO YOU HAVE ANY ACTIONS PENDING AGAINST YOU?

YES

NO

YES

NO

NO

ARE YOU LEGALLY ELIGIBLE TO

WORK IN THIS COUNTRY?
YES
NO

NO

IF YOU ANSWERED YES TO EITHER OR BOTH OF THESE QUESTIONS, PLEASE USE THE ATTACHED
CONVICTION FORM (S) TO EXPLAIN THE CIRUMSTANCES. A SEPARATE CONVICTION FORM MUST BE USED
FOR EACH OCCURRENCE.
ANY OBJECTIONS TO WORKING NIGHTS, WEEKENDS OR HOLIDAYS?
YES
NO
HAVE YOU EVER BEEN TERMINATED
IF YES, EXPLAIN
FROM A JOB FOR A CAUSE?
YES
NO
IF SELECTED, HOW MUCH NOTICE DO YOU NEED TO GIVE CURRENT EMPLOYER?

YES

WILL YOU NOW OR IN THE FUTURE

REQUIRE SPONSORSHIP FOR AN
IMMIGRATION RELATED
EMPLOYMENT BENEFIT?
YES
NO

MINIMUM SALARY REQUIREMENT:

I certify that the information on this application and any attachments are, to the best of my knowledge and belief,
complete and accurate and that I have not knowingly withheld or falsified any pertinent facts or circumstances.
I hereby authorize MTA Long Island Rail Road or its authorized agents to investigate my background and verify
information provided. I certify that I will advise LIRR of any subsequent changes to this Employment Application.
I understand that any omission or misrepresentation of material fact in this application may result in rejection
of this application or dismissal. I further understand that an employment offer by MTA Long Island Rail Road
maybe contingent on a medical and/or physical examination and the results of the background investigation.
Signature________________________________________________________________Date_________

FOR HR USE ONLY

INTERVIEWED BY:

DATE:

COMMENTS:

Company Policy prohibits discrimination on the basis of race, sex, sexual orientation, color, age, national origin, creed or disability.

Page 5 of 27

GENERAL APPLICATION FOR EMPLOYMENT (Supplemental Form)

Your application will not be considered unless every question is answered.

PERSONAL INFORMATION
LAST NAME (please print)

FIRST

MIDDLE

SS# (Last 4 Digits Only)

ADDITIONAL EMPLOYMENT INFORMATION

5. NAME OF EMPLOYER

REASON FOR LEAVING

EMPLOYMENT DATES(Month/Year)
FROM:
TO:

ADDRESS

SUPERVISORS NAME/TITLE

LAST SALARY

COMPANY TELEPHONE NO.

YOUR TITLE

HR ADDRESS (If Different)

HR TELEPHONE NO.

HR NAME/TITLE

6. NAME OF EMPLOYER

REASON FOR LEAVING

EMPLOYMENT DATES(Month/Year)
FROM:
TO:

ADDRESS

SUPERVISORS NAME/TITLE

LAST SALARY

COMPANY TELEPHONE NO.

YOUR TITLE

HR ADDRESS (If Different)

HR TELEPHONE NO.

HR NAME/TITLE

7. NAME OF EMPLOYER

REASON FOR LEAVING

EMPLOYMENT DATES(Month/Year)
FROM:
TO:

ADDRESS

SUPERVISORS NAME/TITLE

LAST SALARY

COMPANY TELEPHONE NO.

YOUR TITLE

HR TELPHONE NO.

HR NAME/TITLE

CITY

STATE

CITY

STATE

CITY

STATE

HR ADDRESS (If Different)

FOR HR USE ONLY

INTERVIEWED BY:

COMMENTS:

DATE:

ZIP

ZIP

ZIP

I certify that the information on this application and any attachments are, to the best of
my knowledge and belief, complete and accurate and that I have not knowingly
withheld or falsified any pertinent facts or circumstances. I hereby authorize MTA
Long Island Rail Road or its authorized agents to investigate my background and verify
information provided. I certify that I will advise LIRR of any subsequent changes to this
Employment Application.
I understand that any omission or misrepresentation of material fact in this
application may result in rejection of this application or dismissal. I further
understand that an employment offer by MTA Long Island Rail Road maybe
contingent on a medical and/or physical examination and the results of the
background investigation.
Signature_______________________________________Date__________________

Company Policy prohibits discrimination on the basis of race, sex, sexual orientation, color, age, national origin, creed or disability.

Page 6 of 27

GENERAL APPLICATION FOR EMPLOYMENT

CONVICTION FORM (A)
NAME:___________________________________DATE:_____________
SOCIAL SECURITY NUMBER: ____________(LAST 4 DIGITS ONLY)

Please complete the following information thoroughly, specifically and accurately, as this
information will be included in a background investigation.
The term offense includes felonies, misdemeanors, violations, and traffic infractions. A plea of
guilty is a conviction even if you were never imprisoned, were placed on probation, only paid a
fine, were conditionally or unconditionally discharged or received a Certificate of Relief from
Disabilities.
A conviction record or pending charges will not be an automatic bar to employment. Your
application will be considered in its entirety. However, any false statement of fact or
omission thereof, regarding convictions or pending charges may disqualify you from
employment.
In answering the following questions, DO NOT DISCLOSE any conviction that (i) is a
SEALED CONVICTION OR (ii) that is classified as a YOUTHFUL OFFENDER
ADJUDICATION.
(A) Have you ever been convicted of an offense anywhere? Yes
No
(B) If yes, list each conviction on a Supplemental Form A Explanation of Conviction.
(C) Have you been charged with or accused of an offense that is currently pending
against you? Yes
No
(D) If yes, list each pending charge on a Supplemental Form B Explanation of Pending
Charge.

Page 7 of 27

GENERAL APPLICATION FOR EMPLOYMENT

Supplemental Form A- Explanation of Conviction
If you answered yes to the question on page 5 of LIRRs General Application for Employment
Have you ever been convicted of a crime, violation or infraction? (Including Traffic
Convictions) provide the information requested below. Use a separate form for each
conviction.
In answering this question, DO NOT DISCLOSE ANY CONVICTION THAT (i) IS A SEALED
CONVICTION OR (ii) THAT IS CLASSIFIED AS A YOUTHFUL OFFENDER
ADJUDICATION.
DATE OF INCIDENT: ____/____/____COUNTY___________________STATE__________
NAME & LOCATION OF COURT:
_____________________________________________________________________________________
_______________________________________________________________________
EXPLAIN THE INCIDENT IN YOUR OWN WORDS:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________
DATE OF SENTENCE: ____/____/____
SENTENCE:_________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________
Print Name: ___________________________________________________________________
Signature: ______________________________________________ Date:_________________
Social Security No. (Last 4 digits Only)________________________
Reviewed by
HR Representative:_______________________Date:______________________________

Page 8 of 27

GENERAL APPLICATION FOR EMPLOYMENT

Supplemental Form B- Explanation of Pending Charge
If you answered, yes to the question on page 5 of LIRRs General Application for Employment
Do you have any actions pending against you? provide the information requested below.
Use a separate form for each pending charge.

DATE OF INCIDENT: ____/____/_____COUNTY_______________STATE__________

NAME & LOCATION OF COURT:
_____________________________________________________________________________________
_______________________________________________________________________
EXPLAIN THE CHARGE IN YOUR OWN WORDS:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Print Name: _________________________________________________________________________
Signature: ________________________________________Date:_________________
Social Security No. (Last 4 digits Only)________________________
Reviewed by
HR Representative:_______________________Date:______________________________

Page 9 of 27

Attachment A-Policy 2103-Avoidance of Nepotism

APPLICANT RELATIVE DISCLOSURE FORM

It is the policy of the MTA Long Island Rail Road (LIRR) to make employment decisions based solely on
merit. In addition, the employment or placement of family members that would result in a conflict of interest
is prohibited.
The MTA Code of Ethics defines a family member as (i) an LIRR employees spouse, domestic partner,
child or sibling; (ii) a person who is a direct descendant (or the spouse of a direct descendant) of a
grandparent of the LIRR employee or a grandparent of the LIRR employees spouse or domestic partner; or
(iii) any person living in the same household as an LIRR employee.
Are you aware if any of your family members have applied for employment with the MTA Long Island
Rail Road (LIRR) within the last twelve (12) months?
Yes
No
(Check one)
To the best of your knowledge, are any of your family members present or former employees of the
MTA Long Island Rail Road (LIRR) or present or former MTA Long Island Rail Road (LIRR) union officials?
Yes
No
If you answered yes to either of the above questions, state with respect to each such Relative:
Name
_________________________________________________________________
Relationship _________________________________________________________________
Position
_________________________________________________________________
Department
_________________________________________________________________
Name
Relationship
Position
Department

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Name
Relationship
Position
Department

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

This statement becomes part of the employment application and is subject to the same provisions
regarding false and misleading information.
I,___________________________, certify that the information given above is true and that I have not
knowingly withheld any facts. It is understood that any false statements will be grounds for rejection
of my application or dismissal.
Signature:__________________________________

Dated:___________________________

HR Representative:__________________________

Dated:___________________________

Page 10 of 27

REFERRAL SOURCE
Please indicate how you were referred to the MTA Long Island Rail Road.
Please check appropriate box:

Newspaper Advertisement (Name of Newspaper)_____________________

Other Advertisement__________________________________________
LIRR Employee______________________________________________
Website_____________________________________________________
Job Fair_____________________________________________________
Job Posting__________________________________________________
Unsolicited__________________________________________________
College Placement____________________________________________
Professional Organization______________________________________
State Employment Agency______________________________________
Keeping Track Pamphlet______________________________________
Other_______________________________________________________

Page 11 of 27

APPLICANT DATA FLOW QUESTIONNAIRE

To The Candidate: Completion of this questionnaire is voluntary

and optional.

The MTA Long Island Rail Road is an Equal Opportunity Employer (M/F/D). The
information requested is to assist us with our record keeping. The information will
kept confidential and will not be used to make a decision about your employment.

Gender:
Ethnicity:

Male

Female

Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central

American, or other Spanish culture or origin, regardless of race.

Race:
White (not Hispanic or Latino) A person having origins in any of the original peoples of
Europe, the Middle East, or North Africa.
Black or African American A person (not Hispanic or Latino) having origins in any of the
Black racial groups in Africa.
Asian (not Hispanic or Latino) A person having origins in any of the original peoples of
the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
Native Hawaiian or Other Pacific Islander A person (not Hispanic or Latino) having
origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
American Indian or Alaska Native (not Hispanic or Latino) A person having origins in any
of the original peoples of North and South America (including Central America), and who
maintain tribal affiliation or community attachment.

Other All persons who identify with two (2) or more of the above five (5) races.

Page 12 of 27

Safety Sensitive Positions

Employees who are newly hired or promoted to Safety Sensitive positions must provide
written consent for the MTA Long Island Railroad (LIRR) to obtain the following
information from Department of Transportation (DOT) regulated employers who have
employed the employee during any period two years before the date of the employees
application or transfer. The following information will be requested:

1.

Alcohol tests with a result of 0.04 or higher alcohol concentration;

2.

Verified positive drug tests;

3.

Refusals to be tested (including verified adulterated or substituted drug test

results);

4.

Other violations of DOT agency drug and alcohol testing regulations;

5.

With respect to an employee who violated a DOT drug and alcohol regulation,
documentation of the employees successful completion of DOT return to duty
requirements (including follow-up tests). If the previous employer does not have
information about the return to duty process (e.g. an employer who did not hire an
employee who tested positive on a pre-employment test) the employee must
provide that information.

Attached is a Supplemental Application for Safety Sensitive Positions. Please complete the
application and print and sign your name where indicated.

Page 13 of 27

SUPPLEMENTAL APPLICATION FOR SAFETY-SENSITIVE POSITIONS

Please answer the following questions, print and sign your name on the space provided:
1.

Have you been employed in a Department of Transportation (DOT) regulated position over the last
two (2) years? Yes
No
If you answered Yes, please list the Company name(s) and addresses where you performed
DOT regulated work in the last two (2) years.
A.________________________________________________________________
B.________________________________________________________________

2.

In the past two (2) years have you been denied employment for a DOT regulated safety-sensitive
position because you tested positive on the pre-employment drug or alcohol test? If you answer Yes,
please provide details pertaining to the positive test result. Yes
No
____________________________________________________________________

3.

In the past two (2) years, have you ever refused to undergo any pre-employment drug or alcohol test
administered by an employer, and were denied employment, for a DOT regulated safety-sensitive work
for which you were applying? If you answer Yes, please provide details pertaining to the refusal to
test. Yes
No

4.

____________________________________________________________________
Have you ever violated a DOT drug and alcohol regulation? If you answer Yes, indicate the employer
you were working for and when this violation occurred. Yes
No
_________________________________________________________________________

5.

If you answered Yes to question #2, #3, and/or #4, you must provide documentation of your
successful completion of DOT return to duty requirements, including follow-up drug and alcohol tests.

As a prospective, newly hired or promoted employee of the MTA-Long Island Rail Road, you are required to
sign an authorization for the LIRR to obtain information from DOT regulated employers who have employed
you during the two (2) years before the date of your application or transfer.
I, (print name)________________________________________________________________,
authorize the MTA Long Island Rail Road to obtain information from DOT regulated employers who have
employed me during the last two (2) years before the date of my application or transfer. I understand that if I
do not provide written consent, I will not be able to perform safety-sensitive functions.
Signature_______________________________________Date:___________________________

Page 14 of 27

Employment Office

DISCLOSURE STATEMENT - ALL APPLICANTS

Have you ever been disciplined in your present or past positions?

Yes

No

You may verify this statement with:

Supervisors Name: ____________________________________________________________
Telephone Number:____________________________________________________________
Company Name: ____________________________________________________________
Company Address: ____________________________________________________________
If the answer to above question is yes, please provide information regarding all such disciplinary action as
indicated below. Please include the date and the details of the incident that led to the disciplinary action and the
final outcome of the disciplinary process.
Complete a separate disclosure statement for each employer.
Date of the incident: ___/____/___
Provide details of the incident:_______________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Disciplinary Action taken:_______________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Date of the incident: ___/____/___
Provide details of the incident:___________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Disciplinary Action taken:_______________________________________________________________________
_______________________________________________________________________________________________
I certify that the information on this disclosure statement is to the best of my knowledge and belief, complete and
accurate and that I have not knowingly withheld or falsified any pertinent fact or circumstances. I hereby
authorize MTA Long Island Rail Road to verify this information.
I understand that any omission or misrepresentation of material fact in this disclosure will result in rejection of
my Employment Application or dismissal.

_________________________________
Print Name

_______________________________
(Human Resources Representative)

________________________
Signature

_____________
Date

_______________________
Date

Authorization-Release (3405)
Revised: 11/11/08

Page 15 of 27

MTA Long Island Rail Road

REFERENCES
NAME:___________________________

DATE:____________

Please provide two (2) professional references in addition to those already included on your Employment
Application, as follows:

(1)
Name:

Job Title:

Company

Telephone No.:

Street
City

State

Zip Code

(2)
Name:

Job Title:

Company

Telephone No.:

Street
City

State

Signature:__________________________________

Zip Code

Date: __________________________

Page 16 of 27

AUTHORIZATION/RELEASE
Current/Prior Employees of MTA Agencies Only
To be completed only by applicants who are currently employed or were previously employed at an
MTA Agency New York City Transit, Metro-North Railroad, Bridges and Tunnels, Business Service Center, Capital
Construction, Headquarters or Long Island Rail Road.
Please provide the MTA Agency name and address and the name and telephone number of
your current or former supervisor at an MTA Agency.

Agency Name:

Job Title:

Supervisor:

Telephone No.:

Company:

Street
City

State

Zip Code

Regarding my application for employment, please furnish The Long Island Rail Road
Company with attendance (3 years), discipline, service records and performance appraisals (if applicable) relating to
my employment with your agency at your earliest convenience.
Records should preferably be faxed to (718) 558 6896 or (718) 523 6888, or mailed to:
The Long Island Rail Road Company
Employment Office, Mail Code 2902 ( Att:________________)
Jamaica Station
Jamaica, New York 11435
I,___________________________, certify that the information given above is true and that I have
not knowingly withheld any facts. It is understood that any false statements will be grounds
for rejection of my application or dismissal.
___________________________________
Print Name
___________________________________
Signature

_______________________________
Date

__________________________________
(Human Resources Representative)

_______________________________
Date

Page 17 of 27

Consent to Request Consumer Report & Investigative Consumer Report Information

Applicant's First Name or Initial

Last Name

I understand that MTA-LIRR (MTA Long Island Rail Road) will use Sterling Infosystems Inc., 1 State Street, New York, NY
10004, (877) 424-2457 to obtain a consumer report and/or investigative consumer report (Report) for employment purposes. I
also understand that if hired, to the extent permitted by law, LONG ISAND RAIL ROAD may obtain further Reports throughout my
employment for an employment purpose from Sterling.
I understand Sterling Infosystems Inc.s (STERLING) investigation may include obtaining information regarding my credit
background, bankruptcies, lawsuits, judgments, paid tax liens, unlawful detainer actions, failure to pay spousal or child support,
accounts placed for collection, character, general reputation, personal characteristics and standard of living, driving record and
criminal record, subject to any limitations imposed by applicable federal and state law.
I understand such information may be
obtained through direct or indirect contact with former employers, schools, financial institutions, landlords and public agencies or
other persons who may have such knowledge. If an investigative consumer report is being requested, I understand such information
may be obtained through any means, including but not limited to personal interviews with my acquaintances and/or associates or
with others whom I am acquainted.
The nature and scope of the investigation sought is indicated by the selected services below: (Employer Use Only)
Criminal Background Check

Education Verification

Sex Offender Search

SSN Trace/Address Locator

Employment Verification

OFAC/Terrorist Watch List

Motor Vehicle Report

Personal Reference Verification

Fraud & Abuse Control Info System (FACIS)

Employment Credit Report

Professional License/Certification

Office of Inspector General Sanctions (OIG)

Other Please List:

I acknowledge receipt of the attached summary of my rights under the Fair Credit Reporting Act and, as required by law, any related
state summary of rights (collectively Summaries of Rights).
This consent will not affect my ability to question or dispute the accuracy of any information contained in a Report. I understand if
LONG ISAND RAIL ROAD makes a conditional decision to disqualify me based all or in part on my Report, I will be provided with a
copy of the Report and another copy of the Summaries of Rights, and if I disagree with the accuracy of the purported disqualifying
information in the Report, I must notify LONG ISAND RAIL ROAD within five business days of my receipt of the Report that I am
challenging the accuracy of such information with STERLING.
I hereby consent to this investigation and authorize LONG ISAND RAIL ROAD to procure a Report on my background.
In order to verify my identity for the purposes of Report preparation, I am voluntarily releasing my date of birth, social security
number and the other information and fully understand that all employment decisions are based on legitimate non-discriminatory
reasons.
The name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries
regarding the investigative consumer report is:
Sterling Infosystems, Inc. | 1 State Street, 24th Floor, New York, NY 10004 | 877-424-2457 | or | 5750 West Oaks Boulevard, Ste.
100
Rocklin, CA 95765 | 800-943-2589 |or | 6111 Oak Tree Boulevard, Independence, OH 44131 |800-853-3228

California, Maine, Massachusetts, Minnesota, New Jersey & Oklahoma Applicants Only: I have the right to request
a copy of any Report obtained by LONG ISAND RAIL ROAD from STERLING by checking the box. (Check only if you wish to
receive a copy)

California, Colorado, Connecticut, Maryland, Oregon, Vermont and Washington State Applicants Only (AS
APPLICABLE): I further understand that LONG ISAND RAIL ROAD will
not obtain information about my credit history, credit
worthiness, credit standing, or credit capacity unless: (i) the information is required by law; (ii) I am seeking employment with a
Page 18 of 27

financial institution (California, Colorado, Connecticut and Vermont only in California the financial institution must be subject to
Sections 6801-6809 of the U.S. Code and in Vermont it must be a financial institution as defined in 8 V.S.A. 11101(32) or a
credit union as defined in 8 V.S.A. 30101(5)); (iii) I am seeking employment with a financial institution that accepts deposits
that are insured by a federal agency, or an affiliate or subsidiary of the financial institution or a credit union share guaranty
corporation that is approved by the Maryland Commissioner of Financial Regulation or an entity or an affiliate of the entity that is
registered as an investment advisor with the United States Securities and Exchange Commission (Maryland only); (iv) I am
seeking employment in a position which involves access to confidential financial information (Vermont only); (v) I am seeking
employment in a position which requires a financial fiduciary responsibility to the employer or a client of the employer, including
the authority to issue payments, collect debts, transfer money, or enter into contracts (Vermont only); (vi) the LONG ISLAND
RAIL ROAD can demonstrate that the information is a valid and reliable predictor of employee performance in the specific
position being sought or held; (vii) I am seeking employment in a position that involves access to an employers payroll
information (Vermont only); (viii) the information is substantially job related, and the bona fide reasons for using the
information are disclosed to me in writing, (complete the question below) (Colorado, Connecticut, Maryland, Oregon and
Washington only);(ix) I am seeking employment as a covered law enforcement officer, emergency medical personnel, firefighter
police officer, peace officer or other law enforcement position (California, Oregon and Vermont only - in Oregon the police or peace
officer position must be sought with a federally insured bank or credit union and in Vermont the law enforcement officer position
must be as defined in 20 V.S.A. 2358, the emergency medical personnel must be as defined in 24 V.S.A. 2651(6), and the
firefighter position must be as defined in 20 V.S.A. 3151(3)); (x) the LONG ISAND RAIL ROAD reasonably believes I have
engaged in specific activity that constitutes a violation of law related to my employment (Connecticut only); (xi) I am seeking a
position with the state Department of Justice (California only); (xii) I am seeking a position as an exempt managerial employee
(California only); and/or (xiii)) I am seeking employment in a position (other than regular solicitation of credit card applications at
a retail establishment) that involves regular access to all of the following personal information of any one person: bank or credit
card account information, social security number, and date of birth,, I am seeking employment in a position that requires me to be
a named signatory on the employers bank or credit card or otherwise authorized to enter into financial contracts on behalf of the
employer, I am seeking employment in a position that involves access to confidential or proprietary information of the LONG ISAND
RAIL ROAD or regular access to $10,000 or more in cash (California only).
Bona fide reasons why LONG ISAND RAIL ROAD considers credit information substantially job related (complete if
this is the sole basis for obtaining credit information) or in California and Vermont the LONG ISAND RAIL ROADS
basis for the credit check.

_____________________________________________________________________________________________________

NY Applicants Only: I also acknowledge that I have received the attached copy of Article 23A of New Yorks Correction Law. I
further understand that I may request a copy of any investigative consumer report by contacting STERLING. I further understand
that I will be advised if any further checks are requested and provided the name and address of the consumer reporting agency.
California Applicants and Residents: If I am applying for employment in California or reside in California, I understand I have the
right to visually inspect the files concerning me maintained by an investigative consumer reporting agency during normal business
hours and upon reasonable notice. The inspection can be done in person, and, if I appear in person and furnish proper identification;
I am entitled to a copy of the file for a fee not to exceed the actual costs of duplication. I am entitled to be accompanied by one
person of my choosing, who shall furnish reasonable identification. The inspection can also be done via certified mail if I make a
written request, with proper identification, for copies to be sent to a specified addressee. I can also request a summary of the
information to be provided by telephone if I make a written request, with proper identification for telephone disclosure, and the toll
charge, if any, for the telephone call is prepaid by or directly charged to me. I further understand that the investigative consumer
reporting agency shall provide trained personnel to explain to me any of the information furnished to me; I shall receive from the
investigative consumer reporting agency a written explanation of any coded information contained in files maintained on me.
Proper identification as used in this paragraph means information generally deemed sufficient to identify a person, including
documents such as a valid drivers license, social security account number, military identification card and credit cards. I understand
that I can access the following website http://sterlinginfosystems.com/privacy to view STERLINGS privacy practices, including
information with respect to STERLINGS preparation and processing of investigative consumer reports and guidance as to whether
my personal information will be sent outside the United States or its territories.
Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a
written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

_______________________________________________________________________________
Signature:

_______________
Todays Date:

Page 19 of 27

For Office Use Only Group ID (optional)

For Office Use Only User ID (optional)

For Office Use Only Location / Store # (optional)

F I R S T

MI D D L E

First Name

Middle Name or Initial

L A S T
Last Name

Date of Birth (MMDDYYYY)

Other Names Known By

Male

S O C I A L
Social Security Number

Female

T E L E P H O N E
Primary Telephone Number (no dashes)

S T R E E T

A P T #

Current Address

Apt #

#yrs at this address

*Must include 10 years of residence.

C I T Y
City

State

S T R E E T

Zip Code

A P T #

Previous Address

Apt #

#yrs at this address

*Must include 10 years of residence.

If necessary continue on back.

C I T Y
City

State

Zip Code

D L #
Drivers License Number (no dashes)

License State

E MA I L
Email Address

Signature

Todays Date (MMDDYYYY)

Page 20 of 27

DISCLOSURE AND AUTHORIZATION FOR RELEASE OF

MOTOR VEHICLE RECORD (MVR) INFORMATION

I authorize my employer (or prospective employer) and its designated agents and representatives, including but not limited
to the company's insurance agent(s) and/or legal representative to obtain and review my motor vehicle record (MVR)
information. I voluntarily supply the information necessary to obtain driver license information from any state that I have
been licensed to drive a motor vehicle and release all parties involved from liability for doing so. I have the right, upon
written request, to a complete an accurate disclosure of the nature and scope of the report and a copy of my Consumer's
Rights under the Fair Credit Reporting Act. This authorization shall be valid in original, fax or copy form and shall serve
as an ongoing authorization to procure MVR information on an ongoing basis during my employment, membership or
contract period.

FILL OUT THE INFORMATION BELOW SO YOUR MVR

INFORMATION CAN BE OBTAINED
Full Name:

Date of Birth:
(Type or Print Name Legibly)

Address:
City, State, Zip Code:

Driver License #:
License Class:

Issuing State:

Have you ever held a driver license in any other state other than the above-mentioned issuing state?
YES
NO
If YES, list all state(s)

In the past 5 years have you ever been convicted of a traffic offense (not including parking tickets) in any other state other than
the above-mentioned issuing state?
YES
NO

If YES, list all state(s)

Employee / Prospective Employee Signature

Date

ATTACH A PHOTOCOPY OF DRIVER LICENSE (BOTH SIDES) TO THIS SIGNED FORM

(Revised 4/09)

Page 21 of 27

FAIR CREDIT REPORTING ACT DISCLOSURE AND

AUTHORIZATION FORM
By this document, The Long Island Rail Road Company (LIRR) discloses to you that an investigative
consumer report may be obtained for employment purposes as part of the pre-employment background
investigation, and by your signature below, you authorize the LIRR to obtain such a report. If you are
hired, this authorization shall remain on file and shall serve as an ongoing authorization for the LIRR to
procure investigative consumer reports at any time during your employment. An investigative consumer
report is a report prepared by a consumer reporting agency that may contain information bearing on your
character, general reputation, educational background, criminal history, driving record, personal
characteristics, or mode of living. Such information may be obtained through personal interviews with
your business associates, financial sources, neighbors, friends or others. You have the right to make a
written request, within a reasonable time, for complete disclosure of additional information concerning the
nature and scope of this investigation. Your signature below signifies receipt of the foregoing disclosure
and authorizes the LIRR to obtain the above-described investigative consumer reports.

Print Name: _________________________________________________________________

Signature:

________________________________________________________________

Date:

______/______/______

Page 22 of 27

Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la

Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20006.

A Summary of Your Rights under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and
privacy of information in the files of consumer reporting agencies. There are many
types of consumer reporting agencies, including credit bureaus and specialty agencies
(such as agencies that sell information about check writing histories, medical records
and rental history records). Here is a summary of your major rights under the FCRA.
For more information, including information about additional rights, go to
www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection
Bureau, 1700 G Street N.W., Washington, DC 20006.

You must be told information in your file has been used against you.
Anyone who uses a credit report, another type of consumer report, to deny your
application for credit, insurance, or employment or take another adverse action
against you must tell you, and must give you the name, address, and phone
number of the agency that provided the information.

You have the right to know what is in your file. You may request and obtain
all the information about you in the files of a consumer reporting agency (your
file disclosure). You will be required to provide proper identification, which may
include your Social Security number. In many cases, the disclosure will be free.
You are entitled to a free file disclosure if:

o A person has taken adverse action against you because of information in

your credit report;
o You are the victim of identity theft and place a fraud alert in your file;
o Your file contains inaccurate information as a result of fraud;
o You are on public assistance;
o You are unemployed but expect to apply for employment within 60 days.
In addition, all consumers are entitled to one free disclosure every 12 months upon
request from each nationwide credit bureau and from nationwide specialty consumer
reporting agencies.
See www.consumerfinance.gov/learnmore for additional
information.

You have the right to ask for a credit score. Credit scores are numerical
summaries of your credit-worthiness based on information from credit bureaus.
You may request a credit score from consumer reporting agencies that create
scores or distribute scores used in residential real property loans, but you will
have to pay for it. In some mortgage transactions, you will receive credit score
information for free from the mortgage lender.

You have the right to dispute incomplete or inaccurate information. If you

identify information in your file that is incomplete or inaccurate, and report it to
the consumer reporting agency, the agency must investigate unless your dispute
is frivolous. See www.consumerfinance.gov/learnmore for an explanation of
dispute procedures.
Page 23 of 27

Consumer reporting agencies must correct or delete inaccurate,

incomplete, or unverifiable information.
Inaccurate, incomplete or
unverifiable information must be removed or corrected, usually within 30 days.
However, a consumer reporting agency may continue to report information it has
verified as accurate.

Consumer reporting agencies may not report outdated negative

information. In most cases, a consumer reporting agency may not report
negative information that is more than seven years old, or bankruptcies that are
more than 10 years old.

Access to your file is limited. A consumer reporting agency may provide

information about you only to people with a valid need usually to consider an
application with a creditor, insurer, employer, landlord, or other business. The
FCRA specifies those with a valid need for access.

You must give your consent for reports to be provided to employers. A

consumer reporting agency may not give out information about you to your
employer, or a potential employer, without your written consent given to the
employer. Written consent generally is not required in the trucking industry. For
more information, go to www.consumerfinance.gov/learnmore.

You may limit prescreened offers of credit and insurance you get based
on information in your credit report. Unsolicited prescreened offers for
credit and insurance must include a toll-free phone number you can call if you
choose to remove your name and address from the lists these offers are based
on. You may opt out with the nationwide credit bureaus at 1-888-5-OPTOUT (1888-567-8688).

You may seek damages from violators. If a consumer reporting agency, or in

some cases, a user of consumer reports or a furnisher of information to a
consumer reporting agency violates the FCRA, you may be able to sue in state
or federal court.

Identity theft victims and active duty military personnel have additional
rights. For more information visit www.consumerfinance.gov/learnmore.

You may have additional rights under Article 25 of the NY State General Business Law.
For more information, contact the NYS Attorney General or the NYS Department of
States Division of Consumer Protection. For more information about your federal
rights, contact:
TYPE OF BUSINESS:
1a. Banks, savings associations and credit unions
with total assets of over $10 billion and their
affiliates.
1b. Such affiliates that are not banks, saving
associations, or credit unions also should list, in
addition to the Bureau:

CONTACT:
a. Bureau of Consumer Financial Protection
1700 G Street NW
Washington, DC 2006
b. Federal Trade Commission: Consumer
Response Center FCRA
Washington, DC 20580
(877) 382-4357
Page 24 of 27

2. To the extent not included in item 1 above:

a. National banks, federal savings
associations and agencies of foreign
banks.

a. Office of the Comptroller of the Currency

Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
b.

Federal Reserve Consumer Help Center

P.O. Box 1200
Minneapolis, MN 55480

c.

FDIC Consumer Response Center

1100 Walnut Street, Box #11
Kansas City, MO 64106

b. State member banks, branches and

agencies of foreign banks (other than
federal branches, federal agencies, and
insured state branches of foreign banks),
commercial lending companies owned or
controlled by foreign banks, and
organizations operating under section 25
or 25A of the Federal Reserve Act.
c.

Nonmember Insured Banks, Insured State

Branches of Foreign Banks and insured
state savings associations.

d. Federal Credit Unions

3. Air carriers

d.

National Credit Union Administration

Office of Consumer Protection (OCP)
Division of Consumer Compliance and
Outreach (DCCO)
1775 Duke Street
Alexandria, VA 22314
Asst. General Counsel for Aviation Enforcement &
Proceedings
Department of Transportation
400 Seventh Street SW
Washington, DC 20590

4. Creditors Subject to Surface Transportation

Board

Office of Proceedings, Surface Transportation

Board
Department of Transportation
1925 K Street NW
Washington, DC 20423

5. Creditors Subject to Packers and Stockyards Act

Nearest Packers and Stockyards Administration

area supervisor
Associate Deputy Administrator for Capital Access
United States Small Business Administration
th
406 Third Street, SW, 8 Floor
Washington, DC 20416
Securities and Exchange Commission
100 F Street, NE
Washington, DC 20549
Farm Credit Administration
1501 Farm Credit Drive
McLean, VA 22102-5090
FTC Regional Office for region in which the
creditor operates or
Federal Trade Commission: Consumer Response
Center-FCRA
Washington, DC 20580
(877) 382-4357

6. Small Business Investment Companies

7. Brokers and Dealers

8. Federal Land Banks, Federal Land Bank

Associations, Federal Intermediate Credit Banks,
and Production Credit Associations
9. Retailers, Finance Companies, and All Other
Creditors not Listed Above

Page 25 of 27

NEW YORK CORRECTION LAW

ARTICLE 23-A
LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY CONVICTED OF
ONE OR MORE CRIMINAL OFFENSES
Section 750. Definitions
751. Applicability
Unfair discrimination against persons previously convicted of one or more criminal
offenses prohibited.
Factors to be considered concerning a previous criminal conviction; presumption.
Written statement upon denial of licenses or employment.
Enforcement.
750. Definitions. For the purposes of this article, the following terms shall have the following
meanings:
Public agency means the state or any local subdivision thereof, or any state or local
department, agency, board or commission.
Private employer means any person, company, corporation, labor organization or association
which employs ten or more persons.
Direct relationship means that the nature of criminal conduct for which the person was
convicted has a direct bearing on his fitness or ability to perform one or more of the duties or
responsibilities necessarily related to the license, opportunity or job in question.
License means any certificate, license, permit or grant of permission required by the laws of this
state, its political subdivisions or instrumentalities as a condition for the lawful profession.
Provided, however, that license shall not, for the purposes of this article, include any license or
permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other
firearm.
Employment means any occupation, vocation or employment, or any form of vocational or
educational training. Provided, however, that employment shall not, for the purpose of this
article, include membership in any law enforcement agency.
751. Applicability. The provisions of this article shall apply to any application by any person
for a license or employment at any public or private employer, who has previously been
convicted of one or more criminal offenses in this state or in any other jurisdiction preceded such
employment or granting of a license, except where a mandatory forfeiture, disability or bar to
employment is imposed by law, and has not been removed by an executive pardon, certification
or relief from disabilities or certificate of good conduct. Nothing in this article shall be
construed to affect any right an employer may have with respect to an intentional
misrepresentation in connection with an application for employment made by a prospective
employee or previously made by a current employee.
752. Unfair discrimination against persons previously convicted of one or more criminal
offenses prohibited. No application for any license or employment, and no employment or
license held by an individual, to which the provisions of this article are applicable, shall be
denied or acted upon adversely by reason of the individuals having been previously convicted

Page 26 of 27

of one or more criminal offenses, or by reason of a finding of lack of good moral character when
such finding is based upon the fact that the individual has previously been convicted of one or
more criminal offenses, unless:
There is a direct relationship between one or more of the previous criminal offenses and the
specific license or employment sought or held by the individual; or
the issuance or continuation of the license or the granting or continuation of the employment
would involve an unreasonable risk to property or to the safety or welfare of specific individuals
or the general public.
753. Factors to be considered concerning a previous criminal conviction; presumption.
1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the
public agency or private employer shall consider the following factors:
(a) The public policy of this state, as expressed in this act, to encourage the licensure and
employment of persons previously convicted to one or more criminal offenses.
(b) The specific duties and responsibilities necessarily related to the license or
employment sought or held by the person.
(c) The bearing, if any, the criminal offense or offenses for which the person was
previously convicted will have on his fitness or ability to perform one or more such duties or
responsibilities.
(d) The time which has elapsed since the occurrence of the criminal offense or offenses.
(e) The age of the person at the time of occurrence of the criminal offense or offenses.
(f) The seriousness of the offense or offenses.
(g) Any information produced by the person, or produced on his behalf, in regard to his
rehabilitation and good conduct.
(h) The legitimate interest of the public agency or private employer in protecting
property, and the safety and welfare of specific individuals or the general public.
In making a determination pursuant to section seven hundred fifty-two of this chapter, the public
agency or private employer shall also give consideration to a certificate of relief from disabilities
or a certificate of good conduct issued to the applicant, which certificate shall create a
presumption of rehabilitation in regard to the offense or offenses specified therein.
754. Written statement upon denial of license or employment. At the request of any
person previously convicted of one or more criminal offenses who has been denied a license or
employment, a public agency or private employer shall provide, within thirty days of a request,
a written statement setting forth the reasons for such denial.
755. Enforcement. 1. In relations to actions by public agencies, the provisions of this article
shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil
practice law and rules.
2. In relation to actions by private employers, the provisions of this article shall be enforceable
by the division of human rights pursuant to the powers and procedures set forth in article fifteen
of the executive law, and, concurrently, by the New York City Commission on Human Rights.

Page 27 of 27