ࡱ>  bjbj }jjl!<l""""$zzzP0{|4d%$:^(ϥ*$ !!!!!!!$& :(R!"ͣϥ!"""%"l(!!, ~vzD&4%0d%((""""Form P-1 Rev. 04-04  For Department Use Only  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  ENT PX DX  MISSOURI DEPARTMENT OF TRANSPORTATION www.modot.mo.gov  APPLICATION FOR EMPLOYMENT AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER PLEASE TYPE OR PRINT IN INK. APPLICATION MUST BE COMPLETED IN ITS ENTIRETY TO BE CONSIDERED. Name on Your Social Security Card FORMTEXT       FORMTEXT       FORMTEXT      Date FORMTEXT      (Last)(First)(Middle or Initial)Social Security Number FORMTEXT      County of Legal Residence FORMTEXT      Mailing Address FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      (Street, Route Number, P.O. Box, HRC)(City)(State)(Zip)Applicant s Email Address FORMTEXT      Telephone Numbers( FORMTEXT      )  FORMTEXT      ( FORMTEXT      )  FORMTEXT      (Number Where You can be Contacted Regarding Employment)(Home) Are you at least age 18, a high school graduate or possess a GED? Yes  FORMCHECKBOX  No  FORMCHECKBOX Are you a U.S. citizen? Yes  FORMCHECKBOX  No  FORMCHECKBOX Do you (or your spouse) have any relative(s) employed by this department? Yes  FORMCHECKBOX  No  FORMCHECKBOX If not a citizen, can you submit verification that you are lawfully available for employment in this country? Yes  FORMCHECKBOX  No  FORMCHECKBOX If yes, give name(s) and relationship(s).  FORMTEXT       Do you possess a valid driver s license? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, please designate:Date CDL Expires:  FORMTEXT       FORMTEXT       FORMTEXT      If you have a valid commercial driver s license (CDL): FORMTEXT      (State)(Number)What class do you have?  FORMTEXT      Have you passed the written portion of the CDL test? FORMTEXT      What endorsements do you have? FORMTEXT      Class A FORMTEXT      Class B FORMTEXT      Other FORMTEXT      What CDL restrictions do you have? FORMTEXT       SELECT A MAXIMUM OF THREE TYPES OF WORK THAT YOU ARE INTERESTED ON THE LINES PROVIDED BELOW. (Refer to supplement for answers to commonly asked questions and an explanation of the types of work listed below.) 1.Accounting/Auditing13.Custodial27. Mechanic/Vehicle Repair2.Archaeology (Cultural Resources)/14.Data Entry Operator*28.Paralegal/Legal AssistantEnvironmental*15.Drafting/CADD29.Photography*3.Archaeology Technician*16.Electrician30.Planning Technician4.Attorney17. Electronic Repair31.Print Shop *5.Bookkeeping/Payroll18.General Clerical32.Purchasing/Stocking Operations6.Bridge Maintenance/Painting*19.Geologist33.Real Estate Acquisition7.Building Maintenance and Repair20.Governmental Affairs*34.Risk Management/Safety8.Chemist*21.Highway Construction Technician35.Secretarial9.Civil Engineer**22.Highway Maintenance36.Service Attendant10.Computer Information Specialist/23.Human Resources Management37.Sign Manufacturing*Programmer/System Support24.Journalism/Public Affairs38.Surveying11.Computer Technician25.Legal Secretary39.Transportation Planning12.Core Drill Operation*26.Materials Testing/Inspection/Research * These jobs are located at the Central Office in Jefferson City. ** Questions regarding civil engineer careers contact civil engineer recruiter toll free at 1-877-605-14351.  FORMTEXT      2.  FORMTEXT      3.  FORMTEXT      Other (state only specific occupations, if not noted above)  FORMTEXT       INDICATE TYPE(S) OF EMPLOYMENT YOU WILL ACCEPT FORMCHECKBOX Full-Time (Ongoing in nature, 40 hours per week) FORMCHECKBOX Seasonal (Hired for a specific period normally April to October) FORMCHECKBOX Permanent Part-Time (Ongoing position, which works less than 40 hours per week) FORMCHECKBOX Temporary (Hired on an as-needed basis) FORMCHECKBOX Intern (College student with semester hours hired to work mid-May August, or between semester breaks) FORMCHECKBOX Summer Student FORMCHECKBOX Coop Student (Student in civil engineering, information systems, or business administration who rotates school and work schedule) FORMCHECKBOX Emergency (Hired based on sporadic needs, i.e., snow removal, etc.)  RETURN YOUR APPLICATION, IN PERSON OR BY MAIL, TO YOUR FIRST LOCATION PREFERENCE (SEE PAGE 8 FOR DISTRICT ADDRESSES) WHERE IT WILL BE ENTERED INTO THE DEPARTMENT WIDE SYSTEM AND KEPT ON FILE FOR SIX MONTHS. MAXIMUM OF THREE LOCATIONS ONLY.  FORMTEXT      1.Northwest District FORMTEXT      5.Central District and FORMTEXT      8.Springfield Area District FORMTEXT      2.North Central DistrictCentral Office FORMTEXT      9.South Central District FORMTEXT      3.Northeast District FORMTEXT      6.St. Louis Area District FORMTEXT      10.Southeast District FORMTEXT      4.Kansas City Area District FORMTEXT      7.Southwest District Central District (Jefferson City Area) and Central Office are considered as one location preference.Indicate county or counties where you desire employment if not available for all counties within a district  FORMTEXT       Indicate the number of workdays per month of overnight travel you are willing to accept with a job: FORMCHECKBOX  None FORMCHECKBOX  Infrequent (1-3) FORMCHECKBOX  Moderate (4-10) FORMCHECKBOX  Extensive (11-19) FORMCHECKBOX  Full-Time (20-21) EDUCATION AND TRAINING: ALL APPLICANTS MUST COMPLETEAttach a reproduced copy of college transcripts, diplomas, certificates, etc. Type of SchoolName of SchoolCity and StateCircle Highest Year CompletedGraduatedStarting DateEnding DateMajor/ MinorGrade FORMTEXT       FORMTEXT      5678XXXXXXXXXXXXXXXXHigh School/GED FORMTEXT       FORMTEXT      9101112Yes  FORMCHECKBOX  No  FORMCHECKBOX  GED  FORMCHECKBOX XXXXXXXXXXXXCollege FORMTEXT       FORMTEXT      1234Obtained Degree? Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      College FORMTEXT       FORMTEXT      1234Obtained Degree? Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      Graduate School FORMTEXT       FORMTEXT      1234Obtained Degree? Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      Business or Vo-Tech School FORMTEXT       FORMTEXT      1234Obtained Degree? Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      Correspondence or Night School FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Courses taken:Accounting FORMTEXT      Algebra FORMTEXT      Biology FORMTEXT      CADD/Microstation FORMTEXT      Calculus FORMTEXT      Chemistry FORMTEXT      Computer Programming  FORMTEXT      Geometry  FORMTEXT      Physics  FORMTEXT      Statistics FORMTEXT      Trigonometry FORMTEXT       Other FORMTEXT       If college credit is earned but no degree, indicate total number of credit hours earned. FORMTEXT      How many additional credit hours do you need to receive your degree? FORMTEXT      Indicate any special courses or training programs not reported above that relate to the type of employment you are seeking.  FORMTEXT       FORMTEXT      Indicate and explain any work-related skills or experience you have obtained through unpaid work, volunteer work, skills developed as a hobby, etc.  FORMTEXT       FORMTEXT      EMPLOYMENT HISTORY: ALL APPLICANTS MUST COMPLETE List previous employment beginning with your present or most recent employer. Show all dates of unemployment. Include any military service, self-employment, and unpaid work experience. Include additional sheets, if necessary. NOTE: If a resume is attached, the information listed under Employment Dates must be filled out in its entirety. ** You will need to tab through the fields below. EMPLOYMENT DATESDUTIES: FROM: MO/YRTO: MO/YR FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      EMPLOYER S NAME FORMTEXT       FORMTEXT       FORMTEXT      EMPLOYER S ADDRESS FORMTEXT       FORMTEXT       FORMTEXT      SUPERVISOR S NAME AND TITLETELEPHONE FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      YOUR JOB TITLE FORMTEXT       FORMTEXT       FORMTEXT      BEGINNING SALARYENDING SALARY FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      REASON FOR LEAVING  FORMTEXT      EMPLOYMENT DATESDUTIESFROM: MO/YRTO: MO/YR FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      EMPLOYER S NAME FORMTEXT       FORMTEXT       FORMTEXT      EMPLOYER S ADDRESS FORMTEXT       FORMTEXT       FORMTEXT      SUPERVISOR S NAME AND TITLETELEPHONE FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      YOUR JOB TITLE FORMTEXT       FORMTEXT       FORMTEXT      BEGINNING SALARYENDING SALARY FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      REASON FOR LEAVING  FORMTEXT      EMPLOYMENT DATESDUTIES: FROM: MO/YRTO: MO/YR FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      EMPLOYER S NAME FORMTEXT       FORMTEXT       FORMTEXT      EMPLOYER S ADDRESS FORMTEXT       FORMTEXT       FORMTEXT      SUPERVISOR S NAME AND TITLETELEPHONE FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      YOUR JOB TITLE FORMTEXT       FORMTEXT       FORMTEXT      BEGINNING SALARYENDING SALARY FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      REASON FOR LEAVING  FORMTEXT      EMPLOYMENT HISTORY: ALL APPLICANTS MUST COMPLETE CONTINUATION EMPLOYMENT DATESDUTIES: FROM: MO/YRTO: MO/YR FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      EMPLOYER S NAME FORMTEXT       FORMTEXT       FORMTEXT      EMPLOYER S ADDRESS FORMTEXT       FORMTEXT       FORMTEXT      SUPERVISOR S NAME AND TITLETELEPHONE FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      YOUR JOB TITLE FORMTEXT       FORMTEXT       FORMTEXT      BEGINNING SALARYENDING SALARY FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      REASON FOR LEAVING  FORMTEXT      EMPLOYMENT DATESDUTIESFROM: MO/YRTO: MO/YR FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      EMPLOYER S NAME FORMTEXT       FORMTEXT       FORMTEXT      EMPLOYER S ADDRESS FORMTEXT       FORMTEXT       FORMTEXT      SUPERVISOR S NAME AND TITLETELEPHONE FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      YOUR JOB TITLE FORMTEXT       FORMTEXT       FORMTEXT      BEGINNING SALARYENDING SALARY FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      REASON FOR LEAVING  FORMTEXT      EMPLOYMENT DATESDUTIES: FROM: MO/YRTO: MO/YR FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      EMPLOYER S NAME FORMTEXT       FORMTEXT       FORMTEXT      EMPLOYER S ADDRESS FORMTEXT       FORMTEXT       FORMTEXT      SUPERVISOR S NAME AND TITLETELEPHONE FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      YOUR JOB TITLE FORMTEXT       FORMTEXT       FORMTEXT      BEGINNING SALARYENDING SALARY FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      REASON FOR LEAVING  FORMTEXT       Date you can begin employment:  FORMTEXT      Minimum salary willing to accept? FORMTEXT      May our department contact your current employer?Yes  FORMCHECKBOX  No  FORMCHECKBOX  SPECIAL SKILLS  LABOR AND TRADES: ONLY APPLICANTS SEEKING EMPLOYMENT IN LABOR AND TRADE JOBS ARE REQUIRED TO COMPLETE THIS SECTION (HIGHWAY MAINTENANCE, MECHANICS, ETC.) Check any of the following skills that you have, based on training or experience:  FORMCHECKBOX Auto/Truck Major Mechanical Repair FORMCHECKBOX Operate Backhoe FORMCHECKBOX Operate Pickup Truck FORMCHECKBOX Auto/Truck Minor Mechanical Repair FORMCHECKBOX Operate Dump Truck FORMCHECKBOX Operate Snowplow FORMCHECKBOX Carpentry FORMCHECKBOX Operate Farm Tractor FORMCHECKBOX Operate Tractor/Trailer Truck FORMCHECKBOX Core Drill Operation FORMCHECKBOX Operate Front End Loader FORMCHECKBOX Sandblasting FORMCHECKBOX Electrician FORMCHECKBOX Operate Heavy Excavation Equipment FORMCHECKBOX Structural Steel Painting FORMCHECKBOX Jackhammer Operation FORMCHECKBOX Operate Light Excavation Equipment FORMCHECKBOX Surveying FORMCHECKBOX Landscape Construction/Maintenance FORMCHECKBOX Operate Motorgrader FORMCHECKBOX Welding FORMCHECKBOX Other Skills FORMTEXT        SPECIAL SKILLS  CLERICAL: ONLY CLERICAL APPLICANTS ARE REQUIRED TO COMPLETE THIS SECTION Check any of the following skills that you have, based on training or experience:  FORMCHECKBOX Applications: Spreadsheet/Database FORMCHECKBOX Word Processing FORMCHECKBOX Telephone/Receptionist FORMCHECKBOX 10-Key Data Entry FORMCHECKBOX Bookkeeping FORMCHECKBOX Shorthand/Transcription FORMCHECKBOX Typewriter (WPM) FORMTEXT       FORMCHECKBOX Other FORMTEXT        PROFESSIONAL CREDENTIALS: ONLY APPLICANTS SEEKING A JOB NORMALLY REQUIRING PROFESSIONAL CREDENTIALS ARE TO COMPLETE THIS SECTION Registered EngineerYes  FORMCHECKBOX No  FORMCHECKBOX If yes, list State and Reg. No. FORMTEXT      Engineer in TrainingYes  FORMCHECKBOX No  FORMCHECKBOX If yes, indicate Enrollment No. FORMTEXT      Registered Land SurveyorYes  FORMCHECKBOX No  FORMCHECKBOX If yes, list State and Reg. No. FORMTEXT      Licensed AttorneyYes  FORMCHECKBOX No  FORMCHECKBOX If yes, list State and License No. FORMTEXT      Certified Real Estate AppraiserYes  FORMCHECKBOX No  FORMCHECKBOX If yes, indicate State, General, or Residential FORMTEXT      NICET CertificationYes  FORMCHECKBOX No  FORMCHECKBOX If yes, indicate level FORMTEXT      Other Licenses or Registrations FORMTEXT        MILITARY RECORD: ALL APPLICANTS MUST COMPLETE If you are a male between 18 and 26 years of age, have you registered with the Selective Service System?Yes  FORMCHECKBOX No  FORMCHECKBOX Have you ever served in the U.S. Military Service?Yes  FORMCHECKBOX No  FORMCHECKBOX If yes: a) Are you an honorable discharged veteran? b) State branch and period of active service Yes  FORMCHECKBOX No  FORMCHECKBOX  FORMTEXT       FORMTEXT      (Branch)(Period of Active Service)NOTE:A dishonorable or general discharge is not an absolute bar to employment and other factors will affect the final decision regarding employment. APPLICANT S SIGNATURE: APPLICANT MUST SIGN APPLICATION I understand that my application will be active for six months and, upon my request, is renewable for an additional six months. I certify that the information provided herein is true and complete to the best of my knowledge. I understand misrepresentation or omission of information on this application and/or inserts, including relatives working for the department, educational attainments, work history, professional credentials, criminal history, etc. is cause for rejection of my application or subsequent dismissal from employment.PRINT FORM, THEN SIGN WITH BLUE PEN BEFORE SUMITTING TO MODOT HUMAN RESOURCES (Signature)Failure to complete and sign the application and the following forms: DRUG TESTING, ALCOHOL TESTING, AND PRE-EMPLOYMENT, POST-OFFER MEDICAL EXAMINATION CONSENT; AUTHORIZATION TO RELEASE INFORMATION CONSENT, AND BACKGROUND CHECK AUTHORIZATION will cause your application to not be considered for employment. MISSOURI DEPARTMENT OF TRANSPORTATION This form must be completed and returned with your application. Please be sure to sign and date.  DRUG TESTING, ALCOHOL TESTING, AND PRE-EMPLOYMENT, POST-OFFER MEDICAL EXAMINATION CONSENT Drug Testing: It is the intent of the Missouri Department of Transportation to provide a drug-free workplace to protect the health and safety of employees and the general public. All applicants offered employment with the department must successfully pass a urine specimen drug test, at department expense. Applicants who fail the drug test, or applicants who refuse to be tested or fail to report for a drug test, will not be considered again for employment for a 12-month period. I understand that any employment offer will be contingent upon my passing the drug test. Alcohol Testing: I understand if I am employed in a job requiring a commercial drivers license at the time of my termination from the Missouri Department of Transportation, the department has my permission to release any drug test and/or alcohol test results to an employer requesting this information. Pre-Employment, Post-Offer Medical Examination: Applicants offered employment with the Missouri Department of Transportation are required to submit to a medical examination, at department expense, to determine if they are able to perform all essential job duties, with or without reasonable accommodation, to ensure the safety, health, and welfare of department employees and the general public. I understand that any employment offer will be contingent upon the successful completion of this pre-employment, post-offer medical examination.  AUTHORIZATION TO RELEASE INFORMATION CONSENT I hereby request and authorize you to furnish the Missouri Department of Transportation with any and all information they may request concerning my employment record, driving record, education record, military record, and the release of any information pertaining to drug and/or alcohol testing and physical exam results with a previous employer. This authorization is specifically intended to include any and all information of a confidential or privileged nature as well as photocopies of such documents, if requested. The information will be used for the purpose of determining my eligibility for employment with the Missouri Department of Transportation. I hereby release you and your organization from any liability, which would result from furnishing the information requested above or from any subsequent use of such information in determining my qualifications to serve as an employee of the Missouri Department of Transportation. Applicant s Printed Name FORMTEXT       FORMTEXT       FORMTEXT      Social Security No. FORMTEXT      (Last)(First)(Middle or Initial) If you were previously employed under a different name(s), please specify FORMTEXT      PRINT FORM, THEN SIGN SIGNATURE WITH BLUE PEN BEFORE SUBMITTING TO MODOT  HUMAN RESOURCESApplicant s SignatureDate FORMTEXT       MISSOURI DEPARTMENT OF TRANSPORTATION AFFIRMATIVE ACTION SURVEY Data provided below is voluntary and is not required in order to submit an Application for Employment. This data will assist the department in analyzing affirmative action statistics. NOTE: This portion of the application will be removed and retained separate from the application files. Name FORMTEXT       FORMTEXT       FORMTEXT      Social Security No. FORMTEXT      (Last)(First)(Middle or Initial)Date Completed FORMTEXT      Date of Birth FORMTEXT       Sex: Male  FORMCHECKBOX Female  FORMCHECKBOX  Race/Ethnic Group  FORMCHECKBOX Caucasian (White)All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East. FORMCHECKBOX African-AmericanAll persons having origins in any of the black groups of Africa, as well as those identified as Jamaican, Trinidadian, and West Indian. FORMCHECKBOX Hispanic (Spanish American)All persons of Mexican, Puerto Rican, Cuban, Central American, South American, or other Spanish culture or origin, regardless of race. FORMCHECKBOX American Indian and Alaskan NativeAll persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition, including Eskimos and Aleuts. FORMCHECKBOX Asian and Pacific IslandersAll persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, and the Pacific Islands. This includes for example, Chinese, Japanese, Korean, Filipino, East Indian, Pakistani, Samoan, Malaysians, Thais, etc.  Check any Applicable  FORMCHECKBOX Vietnam Era VeteranAny part of military service which was during the period August 5, 1964, through May 7, 1975, with active duty service of more than 180 days and discharged or released with other than a dishonorable discharge or was discharged or released from active duty because of a service connected disability. FORMCHECKBOX Disabled VeteranDischarged or released from military service because of service connected disability, or rated 30% or more disabled, or rated 10 or 20% disabled under 38 U.S.C., Section 1506, to have a serious employment disability. Indicate what prompted you to apply for employment with the department:  FORMCHECKBOX No one referred me, just familiar with the department FORMCHECKBOX Referred by the Missouri Division of Employment Security FORMCHECKBOX Referred by a Friend FORMCHECKBOX Newspaper Advertisement FORMCHECKBOX Referred by a Department Employee FORMCHECKBOX A Job Opportunity Announcement FORMCHECKBOX Recruited by a Department Representative FORMCHECKBOX Referred by a Teacher FORMCHECKBOX Internet FORMCHECKBOX College Campus Recruitment FORMCHECKBOX Career Fair FORMCHECKBOX Other  FORMTEXT       FORMCHECKBOX Involved in Transportation and Civil Engineering Program (TRAC) MISSOURI DEPARTMENT OF TRANSPORTATION CENTRAL OFFICE AND DISTRICT ADDRESSES Central Office Missouri Department of Transportation 105 West Capitol Avenue P.O. Box 270 Jefferson City, Missouri 65102 Toll Free 1-877-605-1435 (Human Resources) District 1 - Northwest Missouri Department of Transportation 3602 North Belt Highway P.O. Box 287 St. Joseph, Missouri 64502 (816) 387-2350District 6 St. Louis Area Missouri Department of Transportation 1590 Woodlake Drive Chesterfield, Missouri 63017-5712 (314) 340-4100 (314) 340-4115 (Human Resources) District 2 North Central Missouri Department of Transportation 902 North Missouri Street P.O. Box 8 Macon, Missouri 63552 (660) 385-3176District 7 - Southwest Missouri Department of Transportation 3901 East 32nd Street P.O. Box 1445 Joplin, Missouri 64802 (417) 629-3300 District 3 - Northeast Missouri Department of Transportation 1711 South Highway 61 P.O. Box 1067 Hannibal, Missouri 63401 (573) 248-2490District 8 Springfield Area Missouri Department of Transportation 3025 East Kearney M.P.O. Box 868 Springfield, Missouri 65801 (417) 895-7600 District 4 Kansas City Area Missouri Department of Transportation 600 Northeast Colbern Road Lees Summit, Missouri 64086 (816) 622-6500District 9 South Central Missouri Department of Transportation 910 Springfield Road P.O. Box 220 Willow Springs, Missouri 65793 (417) 469-3134 District 5 - Central Missouri Department of Transportation 1511 Missouri Boulevard P.O. Box 718 Jefferson City, Missouri 65102 (573) 751-3322District 10 - Southeast Missouri Department of Transportation 2675 North Main Street P.O. Box 160 Sikeston, Missouri 63801 (573) 472-5333 If you have special needs addressed by the Americans with Disabilities Act, please notify the appropriate district or Central Office. If you are hearing or speech impaired, please contact the Missouri Relay System by calling 1-800-735-2966. Revised: 08/2005  Missouri Department of Transportation BACKGROUND CHECK AUTHORIZATION FORM I authorize the Missouri State Highway Patrol to furnish the Missouri Department of Transportation (MoDOT) any information regarding my criminal history. This includes pending charges and convictions for a misdemeanor or a felony. I authorize the Missouri Department of Revenue to furnish to MoDOT information regarding the status of my drivers license. I do hereby release and forever discharge MoDOT and its officers, agents, and employees, from any and all liability arising out of or in any manner relating to the performance of the above reference checks and the disclosure of any information made with regard thereto. Conviction of a violation of the law is not an automatic bar to employment. Each case is considered on an individual basis; however, falsification of the application will result in disqualification. I have read and understand the above paragraphs. Name:  FORMTEXT      Name: FORMTEXT      (Print Last, First, MI) (If applicable, include Jr., Sr., etc.)(Please list any previous names.)Signature: Date: FORMTEXT      Social Security Number: (Please list any previously used social security numbers.) FORMTEXT      Have you ever been convicted or plead guilty before a court of any federal, state, or municipal criminal offense? (Please include any alcohol or drug related driving offenses or any other offense you have been convicted of.) If YES, please provide explanation below:  FORMCHECKBOX  YES  FORMCHECKBOX  NO FORMTEXT       FORMTEXT      Have you ever received probation or community supervision for any federal, state, or municipal criminal offense? If YES, please provide an explanation below:  FORMCHECKBOX  YES  FORMCHECKBOX  NO  FORMTEXT       FORMTEXT      Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States? If YES, please provide an explanation below:  FORMCHECKBOX  YES  FORMCHECKBOX  NO FORMTEXT       FORMTEXT      As of the date of this authorization, do you have any pending criminal charges against you? If YES, please provide an explanation below:  FORMCHECKBOX  YES  FORMCHECKBOX  NO FORMTEXT       FORMTEXT       FOR DEPARTMENT OF TRANSPORTATION USE ONLYJob Title: FORMTEXT      District/Division/Office: FORMTEXT      SAM II Access: FORMCHECKBOX  Yes FORMCHECKBOX  NoDate of Birth: FORMTEXT      Gender: FORMTEXT      Purchasing Authority: FORMTEXT       -  PAGE 1 - -  PAGE 9 -  EMBED Word.Picture.8   EMBED Word.Picture.8  "9<=KLMRSabcijxyz{35̵̨̛—ztqtqzqqCJ 5CJ\jCJUmHnHu56CJ\] 56\]5\j6CJU]jt6CJU]j6CJU]j6CJU] 6CJ] 6>*CJ]'j56>*CJU\]mHnHuj5CJU\mHnHuCJ+ {45R $$Ifa$`1$$Ifl* 64 la$Ifp=XF$$Ifl0T*H64 la$If$If`i$$Ifl         0      64 l` a   $&(2468LNPZ\^hj~   "$.02fh|~jCJUjCJUjCJUj,CJUCJjCJUjDCJUjCJUjCJUmHnHuj\CJUCJ jCJU:6^ho$$Ifl4PrX "*%@64 la $$Ifa$$If  2fh$If$Ifm$$Ifl4a\T*%d64 la(P||| $$Ifa$$If$Ifm$$Ifl4\T<*( ` 64 la$&(*>@BLNT     $ & * N P R f h j t v | ~ ? @ jCJUjLCJUjCJUj^CJUjCJUCJjpCJUjCJUCJjCJUmHnHu jCJUfhk$$Ifl4\P+h 64 la$If` 6 8 T V X j l ,.0:<>@TVXbd TVjlnxz PRfjCJUjCJUCJjCJUj,CJUj 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