Emergency Ice Service Driver Employment Application, Ice Delivery

PERSONAL INFORMATION

Name*

First Middle Last

Social Security Number*

Present Address*

Street Address Address Line 2 City State ZIP Code

Permanent Address*

Street Address Address Line 2 City State ZIP Code

Email Address*

Day Phone*

Night Phone*

If you are under 18 can you furnish a work permit?*

Yes
No

Drivers License Number*

State*

State

Class*

EMPLOYMENT DESIRED

Position Applied For*

Salary Desired*

Type*

Full Time
Part Time
Temporary
Seasonal

Date you can start*

Are you employed now?*

Yes
No

If so can we contact your current employer?*

Yes
No

Have you ever applied for a position at Emergency Ice INC. before?*

Yes
No

When?*

Where?*

Are you on lay-off and subject to recall?*

Yes
No

Will you travel if job requires?*

Yes
No

Will you relocate if position requires it?*

Yes
No

Will you work overtime if required?*

Yes
No

Are you able to meet the attendance requirements of this position?*

Yes
No

Have you ever been denied a bond required for employment or denied a security clearance?*

Yes
No

Have you been convicted of a felony in the last seven (7) years?*

A conviction does not constitute an automatic bar to employment unless relevant to the type of employment.

Yes
No

If yes, please explain:*

EDUCATION

Academic

Currently Attending

Name & Location of School

# of Years Completed

Did you Graduate?

Yes
No

Subjects Studied

Last Completed

Name & Location of School

# of Years Completed

Did you Graduate?

Yes
No

Subjects Studied

Trade/Other

Currently Attending

Name & Location of School

# of Years Completed

Did you Graduate?

Yes
No

Subjects Studied

Last Completed

Name & Location of School

# of Years Completed

Did you Graduate?

Yes
No

Subjects Studied

VOLUNTARY AFFIRMATIVE ACTION INFORMATION

We comply with government regulation including Affirmative Action. In an effort to comply with requirements regarding government record keeping and other legal obligations, we ask that you complete this data survey. Your cooperation is appreciated. Please be advised that your survey is considered confidential information that will not be used in any employment matters.

Sex*

Male
Female

Race / Ethnic Group*

Hispanic / Latino
Black / African American
White | American
Indian / Alaskan Native
Asian
Pacific Islander / Native Hawaiian
Two or more races

SPECIAL NOTICE TO VIETNAM VETERANS, DISABLED VETERAND AND INDIVIDUALS WITH PHYSICAL OR MENTAL HANDICAPS OR DISABILITIES: Government contractors subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment qualified disabled veteran and veteran of the Vietnam Era, and qualified handicapped individuals.

PLEASE CHECK IF ANY OF THE FOLLOWING ARE APPLICABLE:

VIETNAM ERA VETERAN
DISABLED VETERAN
HANDICAPPED INDIVIDUAL

This information is used to satisfy the Affirmative Action requirements of section 503 of the Rehabilitation Act or necessitated by another federal law or regulation.

SKILLS AND QUALIFICATIONS

Summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work with our company:*

FORMER EMPLOYERS

List below, your last two employers, starting with the most recent one first.

Employer #1

Date Employed From*

Date Employed To*

Name Previous Employer*

First Last

Address of Previous Employer*

Street Address Address Line 2 City State ZIP Code

Salary*

Job Title*

Reason for Leaving*

Employer #2

Date Employed From*

Date Employed To*

Name Previous Employer*

First Last

Address of Previous Employer*

Street Address Address Line 2 City State ZIP Code

Salary*

Job Title*

Reason for Leaving*

FORMER SUPERVISORS

List below, three supervisors for whom you have worked at some point during the last five years.

Name*

Address*

Phone Number*

Years Acquainted*

Name*

Address*

Phone Number*

Years Acquainted*

Name*

Address*

Phone Number*

Years Acquainted*

FOREIGN LANGUAGES

List any foreign languages skills that you have and check the box(es) that best describe your capabilities.

Language

Speak

Fluent
Good
Fair

Read

Fluent
Good
Fair

Write

Fluent
Good
Fair

CONDITIONS OF EMPLOYMENT

I give the Company the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the Company and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

It is understood and agreed upon that any misrepresentation or omission by me in this application will be sufficient cause for cancellation of this application and/or separation from the Company's service if I have been employed. Furthermore, I understand that just as I am free to resign at anytime, the Company reserves the right to terminate my employment at anytime. with or without cause and without prior notice. No supervisor or other representative of the company (except the President of eEmployers Solutions, Inc.) has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the above.

Reporting to work with impaired abilities; or the possession, consumption or distribution of drugs or alcohol on Company or Client premises and/or worksites, she be grounds for disciplinary action, including discharge. A condition of employment includes a willingness on the part of the applicant or employee to agree to physical examination, and/or substance testing, if requested by the Company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy may result in dismissal.

The Company is an Equal Opportunity Employer. The company does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by the local, state, or federal law.

Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation and, failing settlement in mediation, to binding arbitration, in accordance with the rules of the American Arbitration Association. Arbitration shall be conducted in San Antonio, Texas. Each party will select one person to serves as arbitrator. Those arbitrator will in turn select a single arbitrator to hear the matter. Each party is responsible for its own costs and expenses and will share equally the cost and expenses of the Arbitrator. The arbitration will be subject and agree that this agreement involves matters affecting interstate commerce. U.S.C., Section 1-et seq. The parties hereto stipulate and after that this agreement involves matters affecting interstate commerce.

This application is current for on 60 days. At the conclusion of this time, if I have not heard from the Company and still wish be considered for employment, it will be necessary to fill out a new application.

I have carefully read the above Conditions of Employment and I understand and agree to the terms.*

Yes
No

Signature (Type Your Full Name)*

First Middle Last

Date*