* Required Information

Personal Information

Last 3 years address:

Driver’s License Information (This information will be verified)

Driving Experience

Accident Record Last Three (3) Years

Traffic Convictions and Forfeitures (other than parking) Last Three (3) Years


Previous Employment

Professional References

Applicant Must Read and Sign

* I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment,I understand that false or misleading information in my application or interview may result in my release.

* I certify that I understand that Somerset Community Services, Inc. is committed to ensuring that no person is excluded from employment, participation in programming services, or denied the benefits of its transit services n the basis of race, color or national origin, as protected by Title VI of the Civil Rights Act of 1964.

* I hereby voluntarily waive any and all rights I have to privacy and/or confidentiality pertaining to my employment history and work performance insofar as the information is released solely to employers who are evaluating my suitability for employment. This authorization shall remain valid for 90 days from the date of electronic signature.

* I hereby release Somerset Community Services, Inc. from any claims, damages or liabilities of any kind, that may directly or indirectly result from the use, disclosure, or release of such information by any person or party, whether such information is favorable or unfavorable to me, arising from the employment reference as contemplated by this authorization.

* I hereby authorize Somerset Community Services, Inc. or other authorized representatives of the company bearing this release to obtain any information pertaining to my background, including any of the following services, for employment or volunteer purposes: Maryland Criminal Search-Social Security-Credit Report-Federal Civil-Worker’s Compensation-Verification of Education-Maryland Traffic-Sex Offender Registry-Federal Tax Lien-Civil Judgement-Verification of Licensure-Driving Record-Federal Criminal-Verification of Employment

* I hereby fully release and discharge my prospective employer, or other authorized representatives of the company, or other source providing information from all claims and damages arising out of or relating to any investigation of my background for said purposes.

* I authorize Landmark Insurance Company to release my driving record to Somerset Community Services, Inc. upon request.

* I certify that I have read and acknowledge the disclaimer and agree to its terms.

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