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180 Livingston Street EMPLOYMENT OPERATIONS CANVASS INSTRUCTIONS

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180 Livingston Street
Brooklyn, NY 11201
EMPLOYMENT OPERATIONS CANVASS INSTRUCTIONS
We are canvassing names on the exam list referenced in the email sent to you from MTA NYCT in
anticipation of making appointments. In order for you to be considered for this position, you must
respond to this canvass, complete the enclosed pre-employment application form and submit any
required document(s) to indicate your interest. Your name on all documents submitted must match.
Your response must be sent to the email address provided no later than the date indicated in the
email. Failure to respond will result in your name being removed from the list.
This is not an offer of employment – Please Do Not Resign from your present employment until you
have received a job offer and start date.
I am interested in this job (check the box).
Complete the enclosed pre-employment application form and submit it along with this letter, and a copy
of the documents indicated below to the email address that was provided to you).
(You must read all instructions and complete all pages. Incomplete applications will not be accepted.)
You can complete, sign and save the fillable application on your computer or tablet.
Some sections may not be fillable as the information is not applicable at this time.
You must include any Unemployment time when filling out the application.
If you claimed Veterans Credits, submit your DD-214 (Discharge Paper).
If you claimed Disability Credits, submit your disability letter from the Veterans Administration.
If you claimed Legacy Credits, submit a 9/11 Legacy Credit Letter from either the FDNY or NYPD.
If your title requires a High School Diploma or G.E.D, submit a copy.
If your title requires a Driver’s License, CDLB License and/or Permit, submit a copy.
If you have had Drivers’ License in a state other than NY or NJ within the last three years you must
submit the out of state abstract/ driver’s record. This document cannot be more than 30 days old.
See Job Description for further information of position with drivers’ license requirements.
You must email the completed application, this letter, and a copy of the required documents.
You must make a copy of the application and keep for your records.
I am not interested in this job (check the box and Do Not complete any additional documents).
Return this notice to the email address provided in the email sent to you. Write your Full Name, Exam
Number, List Number and the last five digits of your social security number.
Name _________________________________________________
Exam Number _________________________
List Number _____________________________
Last 5 digits of SSN ______________________
After your documents have been received, you will be contacted and notified of any additional
steps that may be required.
For further information, call MTA NYCT Employment Operations at (347) 643-7413.
Monday-Friday (9:00am - 5:00pm).
DOCUMENT TYPE-2 APPOINTMENT
Name:
Today's Date:
New Title:
Pass No.:
Exam No.: List No.: Time Asked to Report:
Telephone No. #1:
E-mail:
Print Clearly
FOR OFFICE USE ONLY - PLEASE DO NOT WRITE BELOW THIS LINE
(LAST)
(FIRST)
(MI)
Appointment Notice
Canvass Letter
Pre-Employment Application
Drug Results
Medical Results
Motor Vehicle Abstract
Motor Vehicle License Form
Motor Vechicle Record Release
Court Transcript/Record
Letter / 5 Year Evaluation
PAR /TAM
Resume
Offer Letter/Conditional Email
Background Questionaire Form
Fingerprint Recepit
HS Dipl. / College Degree
DP-152/153 (Veterans)
DD-214 (Discharge Form)
Veterans Disability Letter
DP-440 (Vet. Disability Claim)
Terms & Conditions (OA/MTA)
Deferred Slip
DS-10 & DS-12 (Updates A&B)
CPD-B (21 Page Booklet)
Acknowledgement (New
Employee Info. Package)
Other _______________
Liaison's Initials
------------------------------------RECALL - FAIL TO REPORT - VERIFICATION------------------------------------
First Phone Call Date:
Time: Respondent's Name:
Response:
Initials:
2nd Phone Call Date:
Time: Respondent's Name:
Response:
Initials:
Date Recall Letter Sent:
Sent By:
FTR
Human Resources\eForms (Rev. 4/18)
PLEASE CHECK ALL DOCUMENT INCLUDED IN PACKAGE
Provisional Temporary
Non-Competitive
Promotion
Permanent
Reinstatement
TA
OA
Section 71
Section 73
(1) TIME-IN
(3) OUT-OF LAB
(SIGNATURE REQUIRED)
(2) TO LAB
Checked By:
Interviewer
I-9 Employment Eligibility
Birth Certificate
US Passport
Employment Authorization Card
Citizenship Papers
License / CDL Permit
Social Security Card
Family Member Disclosure Form
Employee Data Change Form
Dual Employment
Emergency Contact Form
DOT Form
Pending Forms
Retiree/Vet Form (Pink Sheet)
MTA Bus Company
SIR
-
( )
Social Security Number
Demotion
Human Resources\eForms (REV. 11/00)
I UNDERSTAND THAT MY APPOINTMENT OR PROMOTION IS SUBJECT TO
SATISFACTORY FINDINGS OF A DRUG TEST.
TITLE:
EFFECTIVE DATE:
LIST NUMBER:
(Signature)
DRUG SCREENING NOTIFICATION
Name:
Date:
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PRE-EMPLOYMENT APPLICATION
BACKGROUND VERIFICATION QUESTIONNAIRE
Last Name First MI
Title of Position
Home Address, P.O. Box, Number and Street (Apt. No.)
Social Security Number (List other numbers used.)
City and State
Zip Code
Home Telephone
G E N E R A L I N F O R M A T I O N
Please print information in ink. If additional space is needed, attach a separate sheet of paper.
BE SURE ALL QUESTIONS ARE ANSWERED COMPLETELY.
E M P L O Y M E N T I N F O R M A T I O N
Yes
No
If No, enter type of visa and/or alien registration number:
Yes
No
Are you a United States Citizen?
Are you legally eligible to work in the United States?
(Proof of eligibility documentation will be required at the time of hire as required by law.)
Page 1
Mo/Yr Mo/Yr
Supervisor/Telephone:
Work Hours
Per Week:
Start with your present job and work back to the time you left High School including unemployment time. Do not omit any jobs or
required information. If you have more jobs than space permits, request additional Employment Information page(s) to list them. Use
an employment section for each time period you were unemployed. Where placed by a temporary employment agency or union,
specify the name, address and telephone number of both the temporary employment agency or union and the work placements.
Indicate those jobs in which you were self-employed by printing "Self-Employed" and the telephone number next to "Supervisor/
Telephone". Include any previous NYC Transit, MaBSTOA, SIRTOA, MTA HQ, MTA Bus Company, Long Island Rail Road, Metro-North,
Bridges and Tunnel or Capital Construction employment you may have had at ANYTIME.
Supervisor/Telephone:
Work Hours
Per Week:
Mo/Yr Mo/Yr
Supervisor/Telephone:
Work Hours
Per Week:
Mo/Yr Mo/Yr
List other names used, i.e. maiden name, nickname, assumed name.
List your residence(s) in reverse chronological order most recent first for the past 10 years. From Mo/Yr To Mo/Yr
Dates
From To
Employer's Full Name, Address and Zip Code
(include department name if applicable) Title of Position Reason For Leaving
Present
Page 2
E M P L O Y M E N T I N F O R M A T I O N (continued)
Supervisor/Telephone:
Work Hours
Per Week:
Supervisor/Telephone:
Work Hours
Per Week:
Supervisor/Telephone:
Work Hours
Per Week:
Supervisor/Telephone:
Work Hours
Per Week:
Supervisor/Telephone:
Work Hours
Per Week:
Supervisor/Telephone:
Work Hours
Per Week:
Supervisor/Telephone:
Work Hours
Per Week:
Supervisor/Telephone:
Work Hours
Per Week:
Supervisor/Telephone:
Work Hours
Per Week:
Mo/Yr Mo/Yr
Mo/Yr Mo/Yr
Mo/Yr Mo/Yr
Mo/Yr Mo/Yr
Mo/Yr Mo/Yr
Mo/Yr Mo/Yr
Mo/Yr Mo/Yr
Mo/Yr Mo/Yr
Mo/Yr Mo/Yr
Dates
From To
Employer's Full Name, Address and Zip Code
(include department name if applicable) Title of Position Reason For Leaving
Supervisor/Telephone:
Work Hours
Per Week:
Supervisor/Telephone:
Work Hours
Per Week:
Supervisor/Telephone:
Work Hours
Per Week:
Supervisor/Telephone:
Work Hours
Per Week:
Supervisor/Telephone:
Work Hours
Per Week:
Supervisor/Telephone:
Work Hours
Per Week:
Supervisor/Telephone:
Work Hours
Per Week:
Mo/Yr Mo/Yr
Mo/Yr Mo/Yr
Mo/Yr Mo/Yr
Mo/Yr Mo/Yr
Mo/Yr Mo/Yr
Mo/Yr Mo/Yr
Mo/Yr Mo/Yr
E M P L O Y M E N T I N F O R M A T I O N (continued)
Page 2A
Last Name First MI
Social Security Number
Signature
Date
Title of Position
Dates
From To
Employer's Full Name, Address and Zip Code
(include department name if applicable)
Title of Position Reason For Leaving
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Federal and or State law prohibits discrimination in hiring and employment on the basis of race, color, religion, national original, sex age or marital status.
No question on this application is intended to secure information used for such discrimination.
Human Resources\eForms (REV. 07/19)
A P P L I C A N T ' S S T A T E M E N T
Major
# of Credits
Yes
No
Yes
No
Yes
No
E D U C A T I O N I N F O R M A T I O N
Major
# of Credits
Major
# of Credits
M I L I T A R Y I N F O R M A T I O N
Yes
No
Yes
No
2. What was your Military Occupational Specialty (MOS)?
Dishonorable discharges are not an absolute bar to employment. Other factors will effect a final decision.
If hired, your response may be verified.
P R O F E S S I O N A L O R T R A D E L I C E N S E I N F O R M A T I O N
(If the answer is yes, specify type of license or certification, action taken, from/to date and the reason below.)
Page 3
I declare, under penalties of penal law, that I have completed all pages of the Pre-employment Application/Background
Verification Questionnaire and that the statements contained therein are to the best of my knowledge and belief, true and correct
and that I have not knowingly and willingly made a false statement or given information which I know to be false in connection
therewith.
Yes
No
Major
# of Credits
Yes No
4. Are you claiming U.S. Armed Forces Veterans Credits for this position?
Signature Date
List high school, college, graduate school and special training. Write the full name of diploma/degree (for example, High School
Diploma or Bachelor of Arts).
1. Have you served in the U.S. Armed Forces?
If Yes, indicate entry and separation dates.
3. Were you dishonorably discharged?
If Yes, explain:
1. List state professional or trade licenses issued, number and expiration date
2. Was any license/certification held by you ever suspended, restricted or revoked, or have you ever been censured or
disciplined by any licensing or certifying organization?
Yes No
Name and Address Graduate Degree/Diploma Course
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Last Name First MI
Social Security Number
P R I O R E M P L O Y M E N T T E R M I N A T I O N (S)
Page 5
Signature
Date
Title of Position
Were you ever terminated, dismissed, removed (not laid off) or disqualified for a position, including public employment?
If you answer Yes, give full details including dates.
Yes
No
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signature
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NOTIFICATION / AUTHORIZATION / RELEASE OF INFORMATION
I, authorize release of any
(Print Name)
MTA New York City Transit
Employment Operations
180 Livingston Street
Brooklyn, New York 11201
REV. 08/17
records or documents that includes, but is not limited to, employment records, personal
documents, education documents and documents relating to my termination of
employment to the New York City Transit Authority, Manhattan and Bronx Surface Transit
Operating Authority, MTA Bus Company, Staten Island Rapid Transit Operating Authority
and/or MTA Business Service Center (hereinafter referred to as the Authority), their
officers, agents, employees and servants for the preparation of a report or investigation
relating thereto.
The authorization for release of information includes, but is not limited to, matters of
opinion relating to my character, ability, reputation and past performance. I authorize all
persons, schools, companies, corporations and law enforcement agencies to release
such information without restriction or qualification to the Authority, and any of its officers,
agents, employees and servants. I voluntarily waive all recourse and release the above
sources and firms, including the Authority, from liability for complying with this
authorization. I understand that any offer of employment from the Authority will be
contingent upon the results of a number of factors including this background
investigation.
Signature Date
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DISCLOSURE AND AUTHORIZATION FOR RELEASE OF
MOTOR VEHICLE RECORD (MVR) INFORMATION
I authorize New York City Transit Authority, Manhattan and Bronx Surface
Transit Operating Authority, MTA Bus Company, SIRTOA and its designated
agents and representatives 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. 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 so long as
I remain in a title or assignment requiring a driver’s license.
Fill out the information below so your MVR information can be obtained.
(Please type or print information legibly.)
Full Name: ________________________________________________________________________
Last Name First Name
Driver License #:_________________________________________________________
License Class: ______________________________ Issuing State: ______________
__________________
_______________________________
Signature
___________________
Date
DMV Authorization.
Doc February 2011
PRINT NAME AS IT APPEARS ON LICENSE
SOCIAL SECURITY NO. TITLE OF NEW POSITION
PERMANENT
PROMOTION
PROVISIONAL
PROMOTION
TEMPORARY
PROMOTION
PERMANENT
APPOINTMENT
PROVISIONAL
APPOINTMENT
NON-
COMPETITIVE
ADDRESS, CITY, STATE, ZIP CODE
MOTOR VEHICLE LICENSE INFORMATION
If Yes, note here
Indicate the number of years you have possessed a license without any break prior to the present date
Was license denied, suspended or revoked?
Yes
No
From To
Reason
(If none, write "None." If you have nothing pending, write "None and Nothing Pending.")
Motorist I.D. Number State
For further violations (use other side)
Has applicant been involved in an accident during the past three years which resulted in property damage or physical injury? If yes,
please explain.
Explain
a)
c)
d)
f)
Yes
No
Yes
No
b) Location of accident
e) Number of individuals confined to a hospital as a result of the accident
Date
Signature
DECLARATION (TO BE COMPLETED BY APPLICANT)
Human Resources\eForms (REV.06/20)
This appointment is subject to the receipt of a New York State Drivers License, Class B at the end of the training period.
Class
Expiration Date
License Restrictions:
Yes
No
FOR BUS OPERATOR TITLE ONLY. In order to be appointed to the title of Bus Operator you must present evidence that you possess
a license valid in the State of New York. You must have had a Drivers License for at least THREE (3) YEARS immediately prior to
appointment.
FAILURE TO PROVE WITH DOCUMENTS TO THE SATISFACTION OF THE PERSONNEL DEPARTMENT THAT YOU POSSESSED
SUCH LICENSE FOR THE REQUIRED PERIOD OF TIME WILL RESULT IN YOUR DISQUALIFICATION AND THE TERMINATION
OF YOUR SERVICE.
DATE OF BIRTH (MM/DD/YYYY)
"I declare under penalties of the penal law, that I prepared this form and that the statements contained herein are to the best of my knowledge
and belief true and correct and that I have not knowingly and willfully made a false statement or given information which I know to be false in
connection herewith."
Was police report filed
Number of individuals injured
Extent of property damage
Date of accident
SERIOUS MOVING VIOLATIONS OR ACCIDENT RECORD MAY DISQUALIFY. THEREFORE, LIST BELOW ALL PENDING VIOLATIONS FOR
TRAFFIC.
All applicants will be thoroughly investigated. Therefore, any omission or willful misstatement will be cause for disqualification for
employment.
.
NOTE: For out of state (any state other than New York) license holder or any out of state violations, attach abstract of operating record.
DATE OF
VIOLATION
OFFENSE
DISPOSITION
AND FINE
COURT AND LOCATION
New York City Transit
Date: __________________
Print Social
Name: _____________________________________ Security ___________________________
I am a retiree from ________________________New York City/ New York State agency.
Name of agency
I am not a retiree from a New York City/ New York State agency.
_________________________
Candidate’s Signature
I am a Veteran Yes No
I have claimed Veterans Credits before with a government agency within New
York City or New York State.
____________________________
Agency Name
I have not claimed Veterans Credit before with a government agency within New
York City or New York State.
_________________________
Candidate’s Signature
6/28/13
Bus Company
Staten Island Railway
New York City Transit Bus Company Staten Island Railway
Yes No
Yes No
________________________
(Date)
Name ___________________________________________
Social Security No. ________________________________
During the past two years, did you work for any period of time or applied
to work for a DOT regulated employer?
Did you test positive or refused to test on any DOT pre-employment drug
or alcohol test administered by a DOT covered employer for which you
did not get the job?
X _______________________________________ __________________
Applicant Signature Date
If answered yes to any of
the above questions, on the next page, please CLEARLY print the name and
address of the employer and sign the information release statement.
THIS FORM IS FOR MTA
NEW YORK CITY TRANSIT, MTA BUS AND MTA STATEN ISLAND RAILWAY.
OFFICIAL USE ONLY
Page 1 of 2
New York City Transit Bus Company Staten Island Railway
Release of Information Form – 49 CFR Part 40 Drug and Alcohol Testing
________________________
(Date)
Social Security No. _____________________________________
Name _______________________________________
Please CLEARLY print the name and a
ddress of the employer and sign the information release statement.
USE ONE FORM FOR EACH DOT EMPLOYER DURING THE
PREVIOUS TWO YEARS, IF APPLICABLE.
___________________
_____________________
(Telephone #)
Employer Name ________________________________________
Employer Address ____________________________________________
_______________________________________
______________________________________
Designated Employer Representative (if known)
I hereby grant the D
OT regulated employer identified above, permission to release drug and alcohol testing information related to DOT covered drug and
alcohol testing program to MTA New York City Transit for any part of the two year period to the date of this letter. This includes questions one through
five as stated below. I understand that continued employment is contingent on the findings of the USDOT employer verification and further understand
that I will not be hired to perform safety sensitive functions if I refuse to sign below. I understand any misrepresentation may result in a denial of my
employment application, or, if currently an employee, appropriate disciplinary action.
X ___________________________________________ _____________________
Applicant Signature
Date
Dear Employer:
It is NYC Transit's un
derstanding that you are a DOT regulated employer and that the above applicant has/had been employed or has applied to be
employed by you during the past two years.
MTA New York City Transit for employment in a position covered by the U.S Department of Transportation as safety sensitive. Safety sensitive
functions include, but are not limited to: operation of revenue service vehicles including when not in revenue service; operation of non-revenue service
vehicles that require drivers to hold CDLs; dispatch or control revenue service vehicles; maintain revenue service vehicles or equipment used in revenue
service except for contractors to section 18 transit agencies; and provide security and carry firearm. In accordance with the provisions of federal law, 49
CFR Part 40, Section 40.25, we are requesting that you answer the questions below regarding DOT regulated drug and alcohol testing covering any
period during two years prior to the date of this letter. Above please find a signed release granting consent for you to provide the information by the
above applicant.
1. Did the employee have
alcohol tests with a result of 0.04 or higher? YES NO
2. Did the employee have verified positive drug tests? YES NO
3. Did the employee refus
e to be tested? YES NO
4. Did the employee have
violations of DOT agency drug and alcohol testing regulations? YES NO
5. Did a previous employer
report a drug and alcohol rule violation to you? YES NO
6. If you answered "y
es" to any of the above items, did the employee complete the return-to-duty process? YES NO N/A
X _______________________________________________ _____________________
Employer Signature Date
Print Name _____________________________________ Title _____________________________ Contact Number ________________________
Please mail or fax the
information back to:
MTA New York City Transit
Occupational Health Services, Drug Reporting Unit
180 Livingston Street, Room 4026
Brooklyn, NY 11201
Fax (347)643-8186
Thank you for your anticipated cooperation in this matter. Revised 06/2020
Page 2 of 2
Corporate Compliance: Ethics Form-001 Updated January 2017 Page 1 of 2
All Agency Outside Activity Approval Request
HR
-EMP-304
Section 1 - Information and Instructions
(Please Contact Your Supervisor Prior to Completing this Form)
1)
Any employee desiring employment outside the MTA and any of its Agencies (“MTA”)
should complete this form and obtain approval before
eng
aging in any outside activity. If you are an Employee in a policy-making position, you m
ust complete this form and possibly the New York Joint
Commission (“JCOPE”) on Public Ethics Outside Activity Form to request permission to: (a) hold elected or appointed public office, (b) serve as a
director or officer of a profit
-making corporation or institution, (c) serve as a director or officer of a not for profit-
making corporation or institution, that
qualifies as a Prohibited Source, or (d) engage in an outside activity f
rom which you expect to receive more than $5,000 in annual compensation.
See
MTA Code of Ethics
and your Agency Dual/Outside Employment Policies for additional information.
2)
Newly hired employees who wish to continue other outside activities/employment should file this form prior to their appointment date.
If this request
is subsequently denied, you
must terminate your outside activity/employment within two (2) business days of receipt of determination
or in such other
time frame or manner as is request
ed by the employee and approved by your Agency Ethics Officer.
3) Prior to completing thi
s form, you must discuss this matter with
your supervisor and Ethics Officer
who will advise you on how to complete this form,
and the information you must provide
about the outside activity.
Please attach supporting documentation (e.g., job description, details on outside
activity).
Employees in Public-Safety Positions or Safety-Sensitive Titles must consult their Agency Dual/Outside Employment P
olicies for
additional
requirements.
4)
Any approval is based upon your current position and outside activity/employment. If there is any change in either, please contact your
Supervisor
or
Agency Ethics Officer to determine whether a new request is required. You may be requi
red to certify annually that there has been no change in
either your outside activity or your position with the MTA
.
5) If approved
, a copy of the completed form will be sent by your Agency to the Business Service Center for inclusion in your personnel file.
Section 2 - Employee Information
Employee
Name
Policy Maker Yes
No
Date of Request
Employee
Title
BSC ID
Agency
ID or Pass#
(If Applicable)
Agency
Department
Telephone Number
E
-mail Address
Current Work Schedule
Current Hours Worked
Section 3 – Category of Request (Check all that Apply) *Must complete JCOPE Outside Activity Report
Outside Activity Annual
Compensation under
$5,000
Outside Activity Annual
Compensation over $5
,000*
Est. Annual Amount: $ _________
Corporate Officer or Director*
Non Profit Officer or Director
Public Office*
Elected Position*
Section 4 – Nature of Outside Activity
Name of O
rganization
Your
Proposed Title/Position
Organization’s A
ddress
City
State
Zip Code
Nature and type of business, profession, or other outside activity
Does the organization conduct business with any of th
e following
(If Yes,
contact
your Agency Ethics Officer) : MTA or its Agencies;
MTA Contractor or Subcontractor; Any MTA or MTA Agency
Employee.
Detailed description of services to be performed by you (Attached Separate Sheet if Needed)
Work Schedule
Work Hours
Proposed Start Date
Section 5 - Acknowledgement
I acknowledge that the outside activity described above will not be conducted on MTA
or Agency time or using MTA or Agency resources, and th
at in
no way will it interfere with the performance of my responsibilities at the MTA
or Agency. This activity would not, to the best of my knowledge and
belief, constitute a violation of Public Officers Law §73
-a, or §74 or the MTA Code of Ethics, which I have reviewed.
Signature of Employ
ee
Date
Corporate Compliance: Ethics Form-001 Updated January 2017 Page 2 of 2
All Agency Outside Activity Approval Request
HR
-EMP-304
Section 6
–Approval
-
Supervisor
I recommend that the above
-stated outside activity be approved, having determined that this outside activity
would not interfere with the Employee’s
discharge of his or her du
ties to the MTA.
Signature
Date
Print Name
:
Section 7
–Approval
-
Department Head
I
approve the above-stated outside activity based upon the information provided, having determined that this outside activity is appropriate,
considering MTA Code of Et
hics, applicable policies, procedures, and other rules or regulations governing employee conduct which may apply.
Signature
Date
Print Name
:
Section 8 –Approval-Legal/Ethics Officer (Required for Policy Makers and All MTAHQ Employees)
I approve the above-stated outside activity, having determined that this outside activity is appropriate, considering MTA Code of Ethics, this agency’s
applicable policies, procedures, and other rules or regulations governing employee conduct which may apply.
Signature
Date
Print Name
:
Section 9 – Approval-Chief Compliance Officer or Designee (Required for Agency Presidents and all MTAHQ Employees)
I
approve the above-stated outside activity based upon the information provided, having determined that this outside activity is appropriate,
c
onsidering MTA Code of Ethics, applicable policies, procedures, and other rules or regulations governing employee conduct which may apply.
Signature
Date
Print Name
:
DDR#
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180 Livingston Street EMPLOYMENT OPERATIONS CANVASS INSTRUCTIONS

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Completed 23 September 2020

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