Traffic Attendant/Flagger at ECM Energy Services

First Name *

Middle Initial *

Last Name *

Email *

Cell Phone *

Home Phone

Resume

Date of Birth *

Social Security # *

Which position are you applying for? *

Traffic Attendant/ Flagger
Other - Not Listed

Which location are you interested in? *

Are you at least 18 years of age? *

How did you hear about this opportunity with ECM? *

If you chose 'Referral', who referred you?

Do you have a valid driver's license? *

Do you have reliable transportation to and from work? *

List Driver's Licenses for Previous 3 Years: STATE/ LICENSE #/ CLASS of License/ EXPIRATION DATE. *

List Current Adress and any Other Residency for the past 3 years - STREET, CITY, STATE, ZIP and LENGTH of Time *

Are you legally eligible to be employed within the United States? *

Is there any reason you might be unable to perform the job for which you have applied? *

Have you previously worked for ECM Energy Services, Inc.? *

If so, which location and when?

Do you have any relatives currently employed by ECM? *

If so, please list

What shifts are you available to work? *

Rate of pay expected? *

Employment History

Employer #1 Name and Address/City/State/Zip *

Employer #1 Contact Person and Phone Number *

Employer #1 Start and End Dates *

Employer #1 Salary/Hourly Rate during time of Employment *

Position Held with Employer #1 *

Reason for leaving Employer #1? *

Employer #2 Name and Address/City/State/Zip *

Employer #2 Contact Person and Phone Number *

Employer #2 Start and End Dates *

Employer #2 Salary/Hourly Rate during time of Employment *

Position Held with Employer #2 *

Reason for leaving Employer #2? *

Employer #3 Name and Address/City/State/Zip

Employer #3 Contact Person and Phone Number

Employer #3 Start and End Dates

Employer #3 Salary/Hourly Rate during time of Employment

Position Held with Employer #3

Reason for leaving Employer #3?

Employer #4 Name and Address/City/State/Zip

Employer #4 Contact Person and Phone Number

Employer #4 Start and End Dates

Employer #4 Salary/Hourly Rate during time of Employment

Position Held with Employer #4

Reason for leaving Employer #4?

Please select highest level of education *

Last School Attended - Name/City & State

Accident Record for the past 5 years or more - Please supply accident date, nature of accident, fatalities or injuries (if any). If none, please write 'None'. *

Traffic Convictions & Forfeitures (other than convictions) for the past 5 years or more. Please supply location, date, charge and penalty. If none, please write 'None'. *

CRIMINAL RECORD DISCLOSURE - Disclosure of a criminal record or pending charges will not necessarily disqualify you from employment consideration. Each offense will be evaluated on its own with respect to time, circumstances, seriousness and relation to the position you are applying. (Continued next)

CRIMINAL RECORD DISCLOSURE CONT Omission of information, failure to respond to questions regarding criminal record or pending charges may disqualify you from employment consideration.

Have you EVER been convicted, plead guilty or no contest to a crime other than a minor traffic violation? Note: Crimes include misdemeanors, felonies and any other category of crime except traffic infractions. Driving under the influence, with a license or suspended license is NOT considered minor. Information regarding records sealed by a court of law need not be disclosed. *

If yes, please list what category of crime and explain.

Do you have any deferred prosecutions? *

Do you have any criminal charges pending? *

If yes, please explain.

List any trucking, transportation, or other experience that may help you in your work for this Company.

List any courses & training you have not listed elsewhere in this application.

List any special equipment or technical materials you can work with (other than those already shown).

FAIR CREDIT REPORTING ACT - Disclosure: A consumer report may be obtained on you for employment purposes. It may be an “investigative consumer report” that includes information as to your character, general reputation, personal characteristics, and mode of living. (Continued Next)

FAIR CREDIT REPORTING DISCLOSURE CONT- For investigative consumer reports, you have a right to request disclosure of the nature and scope of the report, which involves personal interviews with sources such as your previous employers, friends, or associates. *

FAIR CREDIT REPORTING AUTHORIZATION: I voluntarily and knowingly authorize ECM Energy Services or its authorized agents, for employment purposes only, to obtain or prepare consumer reports or investigative consumer reports as part of the process of my applying for employment, including independent contractor assignments as applicable. (Continued Next)

FAIR CREDIT REPORTING AUTHORIZATION CONT - I understand that if ECM Energy Services hires me or contracts for my services, my consent will apply, and ECM Energy Services or its authorized agents may prepare & obtain consumer / investigative reports throughout my employment or contract period. *

Please provide ALL of the following requested information: First, Middle, & Last Name (along with any other names used); Current Address/From -To; Previous Address/From-To; Social Security Number; Date of Birth; Driver's License # & State *

TO BE READ & SIGNED BY APPLICANT - 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. Any misrepresentation given on this application shall be considered an act of dishonesty. (Continued on next)

TO BE READ & SIGNED CONT.- I authorize ECM Energy Services, Inc. (the employer) to make such investigations & inquiries of my personal, employment, financial or medical history& other related matters as may be necessary in arriving at an employment decision. (cont next)

TO BE READ & SIGNED CONT.- Generally, inquiries regarding medical history will be made only if & after a conditional offer has been made. I hereby release employers, schools, healthcare providers & other persons from all liability in responding to inquiries & releasing information in connection with my application.

TO BE READ & SIGNED CONT.- I agree to furnish such additional information & complete such examinations as may be required to complete my appication file. It is agreed & understood if I qualify and am hired I will be on a probationary period pending final review of background information during such time I may be disqualified without recourse. (cont next)

TO BE READ & SIGNED CONT.- In the event of employment, I understand that false or misleading information given in my application or interviews shall be considered grounds for my dismissal. I understand also that I am required to abide by all rules and regulations of the motor carrier.

ELECTRONIC SIGNATURE -- Type FULL NAME, SOCIAL SECURITY NUMBER and TODAYS DATE. To be used as your electronic signature. *

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