application for employment i che - chem-air understand that information i provide regarding current...

Application for Employment I

I PLEASE PRINT

CHE www.chem-air.com INCORPORATED

P.O. BOX 7241 SHREVEPORT, LOUISIANA 71137-7241 (318) 424-8395

Position(s) Applied For Date of Application

/

Referral Source ❑ Advertisement ❑ Employee ❑ Relative ❑ Government Employment Agency

❑ Walk-in ❑ Private Employment Agency ❑ Other

Name of Source (If Applicable)

Name Last First Middle

Address sues City State Zip Code

Telephone Number ( Social Security Number

If necessary, best time to call you at home is

May we contact you at work? ❑ Yes ❑ No

If yes, work number and best time to call AIM

Pm

If you are under 18, can you furnish a work permit? ❑ Yes ❑ No

Have you filed an application here before? ❑ Yes ❑ No

If yes, give date

Have you ever been employed here before? ❑ Yes ❑ No

If yes, give dates From To

Are you legally eligible for employment in this country? ❑ Yes ❑ No (Proof of U.S. Citizenship or immigration status will be required upon employment.)

Date available for work

Type of employment desired ❑ Full Time ❑ Part Time ❑ Temporary ❑ Seasonal ❑ Educational Cci3Op

Are you on lay-off and subject to recall? ❑ Yes ❑ No

Will you relocate if job requires it? ❑ Yes ❑ No Will you travel if job requires it? ❑ Yes ❑ No

Are you able to meet the attendance requirements of the position? ❑ Yes ❑ No

Will you work overtime if required? ❑ Yes ❑ No

Have you ever been bonded? u Yes ❑ No

Have you been convicted of a felony in the last seven (7) years? 111 Yes ❑ No (Such conviction may be relevant if job related, but does not bar you from employment.)

If Yes, please explain:

1 State Driver's license number

TO BE READ AND SIGNED BY APPLICANT authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an

employment decision_ (Generally, inquires regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release

employers, schools, health care providers and other persons from all liability in responding to inquiries and e=releasing information in connection with my application..-

In the event of employment, I understand that any false or misleading information given in my application or interview(s) may result in discharge. I understand, also that I am required to abide by alt rules and regulations of the Company.

l Understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be conta,:ted, for the purpose of investigating my

safety performance history as required by 49 CFR 39I.23(d) and (e). I understand that I have the right to:

• Review information provided by current/previous employers;

• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer

• Have a rebuttal statement attached to the alleged erroneous information, if the previous dmployer(s) and 1 cannot agree on the accuracy of the information

Signature Date

Employment History (Ask for Additional Employment History form if needed) All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total I

year employment record).

CURRENT OR LAST EMPLOYER: Name: Phone Number( )

Street Address City State Zip

Position Held Immediate Supervisor & Title

Dates Employed from to Hourly Rate/Salary Starting Final

Summarize the nature of work performed

Reasons for Leaving

Were you subject to the FMCSRs** while employed? 111 Yes ❑ No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? 0 Yes 1:11 No Explain any gaps in employment

SECOND LAST EMPLOYER: Name: Phone Number( )





Reasons for Leaving

Were you subject to the FMCSRs'* while employed? ❑ Yes CI No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49

CFR Part 40? ❑ Yes ❑ No Explain any gaps in employment

THIRD LAST EMPLOYER: Name: Phone Number( )





Reasons for Leaving

Were you subject to the FMCSRs** while employed? ❑ Yes 0 No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49

CFR Part 40? El Yes O No Explain any gaps in employment 7.

USE THIS SHEET FOR ADDITIONAL EMPLOYMENT HISTORY INFORMATION

Company - Supervisor's Name -

Address: Phone: (

Position Held: From - To: Salary:

month/year month/year

Reason for leaving

Company: Supervisor's Name -

Address: Phone: ( )

Position Held: From Tit: Salary:


Reason for leaving

Company - Supervisor's Name -

Address: Phone: ( )

Position Held: From - To - Salary:


Reason for leaving

Company: Supervisor's Name:

Address: Phone: ( )

Position Held: From: To: Salary:


Reason for leaving

Company - Supervisor's Name:

Address: Phone: ( )



Reason for leaving


Address: Phone: ( )

Position Held: From: To - Salary:


Reason for leaving


Address: Phone: ( )



Reason for leaving

© Copyright 1998 J. J, KELLER & ASSOCIATES, INC., Neenah, WI • USA - (800) 327-6868 - Printed in the United States

3 425-F

USE THIS SHEET FOR ADDITIONAL EMPLOYMENT HISTORY INFORMATION


Address: Phone: (

Position Held: From To - Salary: month/year month/year

Reason for leaving

Company: Supervisor's Name .

Address: Phone: ( )

Position Held: From: To: Salary: month/year month/year

Reason for leaving


Address: Phone: ( )

Position Held: From: To: Salary - moniWyear month/year

Reason for leaving


Address: Phone: (


Reason for leaving


Address: Phone: ( )


Reason for leaving


Address: Phone:


Reason for leaving


Address: Phone: ( )


Reason for leaving

4

Educational.Background A. List last three (3) schools attended, starting with last one. B. List number of years completed. C Indicate degree or diploma earned, if any D. Grade Point Average or Class Rank and E. Major and minor field of study (if applicable).

A. School B. No Years Completed

C. Degree Diploma

D. CPA Class Rank E. Major E. Minor

References List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who arc not related to you.

Name

Telephone

Years Known

Skills and Qualifications Summarize special skills and qualifications acquired from employment or other experiences that may

qualify you to work with our company. List any foreign language(s) you know

List professional, trade, business, or civic associations and any offices held. (Exclude memberships which would reveal sex, rac< religion, national origin, age, color, disability or other protected status.)

Organization

Offices Held

List special accomplishments, publications, awards. (Exclude information which would reveal sex. race, religion. national origin, age, color, disability or other protected status.)

Have you ever served in the U.S. Military or Coast Guard?

If yes, list branch and dates of service:

CLASS OF EQUIPMENT

Straight Truck

Tractor & Semi-Trailer

Tractor - Two Trailers

Tractor - Three Trailers

(Greater than Motorcoach - School Buss passengers)

(Greater than Motorcoach - School Bus 15 passengers)

Other:

TYPE OF EQUIPMENT (Circle all that apply)

Van, Reefer, Tank, Flat




N/A

N/A

Van, Reefer, Tank, Flat, N/A

DATES FROM TO

Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify that I do not have more than one motor vehicle license, the information for which is listed below.

State License Number Expiration Date

A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? ❑ Yes ❑ No

If yes, give details

B. Has any license, permit, or privilege ever been suspended or revoked? ❑ Yes ❑ No

If yes, give details

EXPERIENCE AND QUALIFICATION Attach separate sheet if more space is needed

Driving Experience If no driving experience within the last 3 years - check here ❑

APPROXIMATE NUMBER OF MILES

OR

Accident History (3 years) If no accidents within the last 3 years - check here ❑

DATE

NATURE OF ACCIDENT

NUMBER OF NUMBER OF CHEMICAL (month/year)

(head-on, rear-end, upset, etc.)

FATALITIES INJURIES SPILL?

❑ YES ❑ NO

❑ YES ❑ NO

❑ YES ❑ NO

Traffic Convictions and Forfeitures (3 years) If no traffic convictions and/or forfeitures in the last 3 years - check here ❑

DATE CONVICTED

VIOLATION

STATE OF VIOLATION

PENALTY (month/year) (Other than violations involving parking only)

(Forfeited bond, collateral and/or points)

License Information

Applicant Certification

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to

the best of my knowledge.

Applicant's Signature Date

6

Voluntary Affirmative Action Information (Completion of information below is voluntary)

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability, veteran status or any other legally protected status.

Date / /

Position(s) applied for

Referral Source

❑ Advertisement ❑ Employee ❑ Relative ❑ Walk-in ❑ School ❑ Government Employment Agency

❑ Private Employment Agency ❑ Other

Name of Source (if Applicable)

Applicants Name Last

First Middle Area Code Phone

Address Street City State Zip Code

As required, we comply with government regulations including Affirmative Action obligations where they apply.

In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations, we ask the you complete this applicant data survey. Your cooperation is appreciated.

Please be advised that your survey is not a part of your official application for employment It is considered confidential information that will not be used in any hiring decision.

Check one: ❑ Male ❑ Female

Check one of the following Race/Ethnic Group

❑ Hispanic ❑ Black ❑ White ❑ American Indian/Alaskan Native ❑ Asian/Pacific Islander

SPECIAL NOTICE TO VIETNAM ERA VETERANS, DISABLED VETERANS 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 veterans and veterans of the Vietnam Era, and qualified handicapped individuals.

You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable accommodation. This information will be considered confidential, and refusal to provide this information will not adversely affect your consideration for employment.

IF YOU SO WISH TO BE IDENTIFIED, PLEASE CHECK IF ANY OF THE FOLLOWING ARE APPLICABLE:

❑ VIETNAM ERA VETERAN ❑ DISABLED VETERAN ❑ INDIVIDUAL WITH A DISABILITY

7

APPLICANT RELEASE OF CONFIDENTIALITY

, hereby authorize my former employer(s), or its (their) agents, and any other person or entity shown on my "Application for Employment" with to respond fully, truthfully, and candidly to all inquiries regarding:

Dates of employment

Position(s) held

Pay and benefits

Safety record

Performance and ability

Discipline and attendance records

Reason for termination

Re-hire status

Other, listed below

[] DO NOT release information about the following -

. . I understand that, without having signed and provided this release, companies i and ndividuals may be r-eluctant to provide information regarding these matters other than dates of employment and position held, and I consider it to my advantage that they release more detailed information. By this authorization, I hold them harmless for the release of information that is accurate and truthful.

Employee's signature

Date

Witness signature 8 Date

ALCOHOL, DRUG AND OTHER CONTRABAND POLICY

This company is committed to providing a safe and efficient workplace for all employees. Experience has shown that the abuse of alcohol, drugs, illegal inhalants, and other intoxicants is harmful to individual and company goals and productivity. Therefore, the company has initiated efforts to prevent the harmful and/or illegal use of such substances. These policies apply to all current and future employees of the company, and violations may result in disciplinary action up to and including discharge

The possession, sale or consumption of alcohol on company premises and/or working under the influence of alcohol is absolutely prohibited. The possession, sale, or use of illegal drugs, or controlled substances without a prescription (or in amounts exceeding one prescription), at any time is prohibited. Applicants and employees may be requested at any time, as a condition of employment, to submit to alcohol/drug testing. Further, the company has the right at any time, without notice, to search any person, vehicle, container, information storage or retrieval system, personal effects, or area located on company property (or work-sites) for company property, contraband and/or prohibited substances. If deemed necessary by management, workers themselves may be asked to submit to a physical search. At no time will any employee be searched by or in the presence of a member of the opposite sex. Refusal to-cooperate with or submit to a search may be treated as serious insubordination warranting immediate discipline, including termination.

Tests that may be used include (but are not limited to) blood tests, as well as urinalysis or other scientific procedures. Any employee using prescription drugs that may cause adverse side effects (i.e. drowsiness or impaired reflexes or reaction time) should inform their supervisor that they are taking such medication on the advice of a physician. It will be necessary to know what side effects are expected, and how long they will be under medication. A decision will be made as to whether the employee may continue to work while using the medication. Any measurable amount of illegal drugs in an employee's system is a violation of this policy.

Off-duty use, sale, or other illegal involveMent with drugs or alcohol in any manner, which could cause adverse impact on community good will toward the company, or result in decreased ability of the company to conduct businesS, will also.be-considered a serious violation of company policy, and result in disciplinary action deemed appropriate by company management.

Employees who are experiencing personal problems related to the use of drugs, alcohol, or other substances are encouraged to initiate a discussion with company management. Employees who initiate such discussions are assured that the information will be held confidential, and only those persons with a legitimate need to know will have access to the information. Management will, in such cases advice the employee in obtaining professional assistance in overcoming the problem_ Such assistance may include providing a Leave of Absence, list of organizations to contact, possible trea_tment facilities, and alternatives that may be available under insurance policies. Active cooperation with such assistance as may be made available may be considered as grounds for the company to exercise leniency in disciplinary measures, or to actively participate in the rehabilitation effort. Failure or unwillingness to comply with rehabilitation assistance, including timely reporting of progress as may be required, may be considered as willful misconduct and/or abandonment of employment.

DRIVERS/APPLICANTS: • No driver shall be on duty if the driver uses any controlled substances. • Pre-employment — This Company requires the Driver-Applicant to be tested for the use of controlled substances. • Biennial — (Periodic) This Company requires its Drivers to be tested for controlled substances at least once every

two years. (Usually at time of medical review) • Reasonable Cause —This Company requires a Driver-Employee to be tested for the use of controlled substances

upon reasonable causes.

I have read or had read to me the company substance abuse policy and acknowledge this policy as a condition of my employment.

SIGNATURE DATE WITNESS

9

ARE YOU PRESENTLY, OR HAVE YOU EVER TAKEN ANY TYPE OF DRUG THAT WOULD

RESTRICT OR IMPAIR YOUR ABILITY TO OPERATE A MOTOR VEHICLE? YES NO .

IF YES, EXPLAIN:

I UNDERSTAND THAT A DRUG TEST WILL BE ADMINISTERED PRIOR TO EMPLOYMENT

WITH THIS COMPANY. I FURTHER UNDERSTAND AND AGREE THAT AT SUCH TIMES

DURING MY EMPLOYMENT, AS THE COMPANY SHALL REQUIRE, I WILL PROVIDE URINE,

BREATH OR BLOOD SPECIMENS TO BE TESTED FOR THE PRESENCE OF DRUGS OR

ALCOHOL.

IF MY PRE-EMPLOYMENT DRUG TEST RESULTS PROVE "POSITIVE", I UNDERSTAND THAT I

AM OBLIGATED TO PAY FOR THE TESTING.

IF MY DRUG TEST RESULTS PROVE "NEGATIVE" AND I AM HIRED, THE COMPANY WILL

PAY FOR MY TESTING FEE.

I HAVE READ, OR HAD READ TO ME, AND UNDERSTAND THE ABOVE STATEMENT AND

CONSENT TO BEING DRUG TESTED.

SIGNATURE DATE

WITNESS

TO BE ELIGIBLE OR PERMI 1 FED TO OPERATE A COMPANY VEHICLE YOU MUST BE

QUALIFIED UNDER INSURABILITY CRITERIA. A REPORT OF YOUR DRIVING RECORD WILL

BE REQUESTED FROM YOUR DRIVERS LICENSE ISSUING STATE'S DEPARTMENT OF

TRANSPORTATION.

A DRIVER DISQUALIFIED FOR ANY REASON BECOMES INELIGIBLE FOR INSURANCE

COVERAGE REQUIRED BY COMPANY POLICY AND IS DISQUALIFIED FOR ANY POSITIONS

THAT REQUIRED DRIVING COMPANY VEHICLES.

I HAVE READ, OR HAD READ TO ME, AND UNDERSTAND THE ABOVE STATEMENT AND

CONSENT TO HAVING MY DRIVING RECORDS RECEIVED.

SIGNATURE DATE

WITNESS

10

Please Read and Initial Each Paragraph Below (if there is any part of this page you do not understand, please ask the interviewer about it before signing).

I hereby authorize this Company to thoroughly investigate my references, work records, education and other matters related to my suitability for employment and, further, authorize my current and former employers to disclose to the company any and all letters, reports and other information pertaining to my employment with them, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my current and former employers, and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I understand that if offered employment, the offer may be contingent on my passing a pre-employment alcohol and drug screen and a pre-employment physical. By signing this application, I voluntarily agree to submit to a pre-employment alcohol/drug screen and pre-employment physical upon request. I understand that failure to pass the alcohol/drug screen and/or physical will result in withdrawal of the employment offer.

If hired, I also agree to submit to alcohol or drug testing as a condition of employment. I agree that this Company may conduct alcohol or drug screening at its sole discretion with or without notice. I also understand that refusal to submit to an alcohol/drug screen will be considered a voluntary resignation of employment.

I understand that nothing contained in the application or conveyed to me during any interview, which may be granted, is intended to create an employment contract, implied or explicit, between the company and me. In addition, I understand and agree that if I am employed, my employment relationship with this Company is strictly voluntary and at our mutual will_ I understand that if employed, my employment is for no definite period and may be terminated at any time, with or without prior notice, with or without cause or reason, at the option of either myself or the company and that no promises or representation contrary to the forgoing are binding on the company unless made in writing and signed jointly by the President/CEO and myself_

I understand and agree that any future changes in my title, duties, compensation, working conditions, and/or the Company benefits; policies and procedures will not alter our at-will agreement.

I understand that if offered employment, I will, as a condition of employment, be required to submit proof of my identity and legal right to work in the United States on my first day of employment.

If the position applied for requires driving in the course of work, I understand that I will be required to possess a current and valid state driver's license and understand that I will be required to provide a copy of my official driving record and proof of insurance. I also understand that any offer of employment is contingent on my ability to be covered by the Company's auto insurance, if required for my position.

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement on this application or on any documents used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

My signature below certifies that I have read and understand this complete page, and agree to the terms and conditions outlined in this document.

Applicant's Signature Date

Witness/Company Date

1 1

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