EMPLOYMENT PACKET v1

Employee Safety Handbook Acknowledgment

Please review the PDF below
I have read the Employee Safety Handbook and understand that by signing below I agree to the terms set forth in the handbook
YOU MUST READ THE ENTIRE SAFETY HANDBOOK BEFORE CONTINUING.
- Name
  
  First NameLast Name
- Signature
- Date
  
  MonthDayYear
  Date

DRUG & ALCOHOL TESTING CONSENT FORM

Please review the PDF below
Name

First NameLast Name
Signature
Date

MonthDayYear
Date

DRIVER RECORD SCREENING DISCLOSURE

Please review the PDF below
Name

First NameMiddle NameLast Name
Driver License Number
State Driver License Issued In
*** California, Minnesota, Massachusetts, Maine, and Oklahoma Applicants
Email
example@example.com
Date of Birth Month / Day / Year
Initial here for acknowledge receipt of Article 23-A of New York Correction Law

INITAL
Signature
Date

MonthDayYear
Date

8850 Pre-Screening Notice and Certification Request for the Work Opportunity Credit

Please review the PDF below
Name

First NameLast Name
Social Security Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
County
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
If you are under age 40, enter your date of birth.

MonthDayYear
Date
Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit.
Check here if any of the following statements apply to you.
• I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.

• I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.

• I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.

• I am at least age 18 but not age 40 or older and I am a member of a family that:
a. Received SNAP benefits (food stamps) for the past 6 months; or
b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.

• During the past year, I was convicted of a felony or released from prison for a felony.

• I received supplemental security income (SSI) benefits for any month ending during the past 60 days.

• I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the
past year.
Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year.
Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year.
Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.
Check here if any of the following statements apply to you.
• Received TANF payments for at least the past 18 months; or

• Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or

• Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.
Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.
Signature
Date

MonthDayYear
Date

Form I-9 Employment Eligibility Verification
Name

Last NameMiddle NameFirst Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth

MonthDayYear
Date
Social Security Number
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I attest, under penalty of perjury, that I am (select one of the following choices)
Alien Registration Number/USCIS Number
Alien authorized to work until expiration date, if applicable

MonthDayYear
Date
Signature
Date

MonthDayYear
Date
Did you use a translator on section 1?
Preparer and/or Translator Certification for Section 1

If you used a preparer and/or translator to help you with you I-9, please have them fill in the information below. If not, scroll to the next portion.
Signature of Preparer or Translator
Date

MonthDayYear
Date
Name of Translator

First NameLast Name

W-4

Employee's Withholding Certificate
Name

First NameMiddle NameLast Name
Social Security Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Filing Status
Multiply the number of qualifying children under the age of 17 by $2,000.00
Multiply the number of other dependents by $500.
Add the amounts above for qualifying children and other dependents. You may add to this the amount of any other credits. Enter the total here.
a) Other Income (not from jobs).
b) Deductions. If you expect to claim deductions other than standard deductions.
c) Extra withholding. Enter any additional tax you want withheld each Pay Period:
Signature
Date

MonthDayYear
Date

W-4N

Employee's Nebraska Withholding Allowance Certificate
Name

First NameMiddle NameLast Name
Social Security Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Note: If married, but legally separated, or spouse is a nonresident alien, check the "Single" box. Individuals filing income tax returns with a "Head of Household" status check the "Single" box.
Total number of allowances you are claiming
Additional amount, if any, you want withheld from each paycheck for Nebraska income tax withheld
I claim exemption from withholding and I can provide satisfactory evidence to my employer that I meet both of the following conditions for exemption. • Last year I had a right to a refund of all Nebraska income tax withheld because I had no tax liability, and • This year I expect a refund of all Nebraska income tax withheld because I expect to have no tax liability. If you can provide evidence that you can meet both conditions, write “Exempt” here
Signature
Date

MonthDayYear
Date

Personal Allowances Worksheet • Allowances approximate tax deductions that may reduce your tax liability. The number of allowances is determined by many factors including, but not limited to, filing status, how many jobs you have, tax credits, and how many children or dependents that you claim on your tax return. Allowances claimed on the Form W-4N are used by your employer to determine the Nebraska state income tax withheld from your wages to meet your Nebraska state income tax obligation.

Rows	Enter 1 or 0 if it doesn't apply to you
a. Enter “1” for yourself if no one else can claim you as a dependent
b. Enter “1” if: • You are single and have only one job; or • You are married, have only one job, and your spouse does not work; or • Your wages from a second job or your spouse’s wages (or the total of both for the year) are $1,500 or less
c. Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld)
d. Enter number of Nebraska personal exemptions (other than your spouse or yourself) you will claim on your Nebraska tax return. This is the number of children and dependents you will list on your Nebraska return that qualify for either the child or dependent tax credit on the federal return
e. Enter “1” if you will file as head of household on your tax return
f. Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit
Enter total of lines a through f here and on line 1 above. (Note: This may be different from the number of exemptions you claim on your Nebraska tax return)

Employee Direct Deposit Authorization

Must be filled out completely in order to get paid!

Account 1 Type
Bank Name
Bank Routing Number
Account Number

Percentage or dollar amount to be deposited to this account:

Rows	$ or %	Amount or Percent to be deposited
Account 1

Attach voided check for this account.

Account 2 Type
Bank Name
Bank Routing Number
Account Number
Attach voided check for this account.

Name

First NameLast Name
Signature
Date

MonthDayYear
Date

Emergency Contact Information
1 Name

First NameLast Name
1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
1 Relationship
1 Address

Street Address

Street Address Line 2

CityState

Zip Code
2 Name

First NameLast Name
2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
2 Relationship
2 Address

Street Address

Street Address Line 2

CityState

Zip Code

Employee Acknowledgment Form

I have read and understand the Employee Acknowledgment Form.
I have read the Employee Handbook and understand that by signing below I agree to the terms set forth in the handbook
YOU MUST READ THE ENTIRE EMPLOYEE HANDBOOK BEFORE CONTINUING
- Name
  
  First NameLast Name
- Signature
- Date
  
  MonthDayYear
  Date

Pre- Existing Injuries Disclosure Form

Integrated Power Company (IPC) has an obligation to ensure the health and well being of all those that work with our company, which we take very seriously.To meet this obligation, we request you advise us of any injury you may suffer from, of which you are aware of, and which did NOT occur during your employment with IPC.
Name

First NameLast Name
Position
Start Date

MonthDayYear
Date
Superintendent / Supervisor
Disclosure of Injury
Please provide details below:
I acknowledge that the information I have provided above is true and correct.
Date

MonthDayYear
Date

Cell Phone Use Policy
Employees who have access to a cellular telephone while operating a vehicle must remember the number one priority is driving safely and obeying the rules of the road. This policy does not include the use of walkie-talkies or 2-way radios used in the course of work.
1. Employees may NOT use hand held cell phones, PDAs or similar wireless devices while driving a companyvehicle or driving a personal vehicle on company business unless the vehicle is equipped with a hands-freespeaking device.
  1. Employees may not initiate telephone calls while driving unless using the voice activated feature of thehands-free device.
  2. If no hands-free device is installed, let the call go to the voice mail and answer when safely stopped.
2. Email and Text messaging are prohibited while driving a company vehicle or a personal vehicle on company business.
Name

First NameLast Name
I acknowledge that the information I have provided above is true and correct.
Date

MonthDayYear
Date

IPC Vehicle Use Agreement
1. As the driver I am responsible to wear my seatbelt and assure all passengers wear their seat belts while the vehicle is in motion. No one is allowed to ride in the back of a truck.
  
  2.     I must be properly licensed to operate the type of vehicle driven.
  
  3.     I will provide Proof of Insurance upon hire and at the beginning of each new policy period to Management. My vehicle insurance policy will maintain the legal limit of insurance as required by the state in which the vehicle is registered.
  
  4.     I will notify my Safety Director immediately of all accidents involving a company vehicle or a personal vehicle driven on company business.
  
  5.     I will report to my Safety Director immediately any traffic citations I receive while operating a company vehicle, a personal vehicle on company business or a personal vehicle away from work.
  
  6.     I am required to submit to a drug/alcohol test after any accidents while operating a company vehicle or a personal vehicle on company business and I will contact my Safety Director immediately after the accident to schedule the drug/alcohol test within four (4) hours of the incident.
  
  7.     I am required to submit to a drug/alcohol test in the event I receive a drug, drug-paraphernalia or alcohol related traffic citation and I will contact my Safety Director immediately upon receipt and submit to a drug/alcohol test within four (4) hours of the incident.
  
  8.     I will keep my Safety Director updated on all citations and whether they result in a conviction or not.
  
  9.     I authorize IPC to review my MVR at will during my employment.
  
  10. I will not operate a vehicle at any time while under the influence of alcohol or drugs.
  
  11. I understand IPC may terminate this agreement at any time, for any reason.
  
  12. A completed copy of the monthly inspection report will be submitted to the Safety Director each month. I am responsible for all repairs to my personal owned vehicle.
  
  13. I will comply with the IPC Cell Phone Use Policy in the IPC Fleet Safety Program
  
  14. I understand smoking is not allowed in company vehicles and will comply.
  
  15. I will comply with all local, state, and federal laws while operating a company vehicle.
  
  16. I am responsible for always ensuring safe and secure parking for the vehicle.
  
  17. Hitchhikers are not permitted in the vehicle.
  
  18. I am responsible for all traffic and parking violations arising from the use of company vehicles. Should IPC be required to pay any fine after my employment is terminated, I will reimburse IPC within 30 days of receiving written notice.
  
  19. Personal use of my IPC vehicle must be approved by Management.
  
  20. Management approval is required to modify or accessorize an IPC vehicle.
  
  21. I will not remove or disable the company vehicle tracking devices.
  
  22. Radar detectors are not allowed in company vehicles.
  
  23. I will always keep the inside of my vehicle clean and in orderly condition.
  
  I have read, understand, and agree to comply with the above and all conditions of the IPC Fleet Safety Program. I understand that if I fail to comply with these responsibilities my driving privileges may be revoked, and I may be subject to disciplinary actions including up to termination of my employment.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature
Date

MonthDayYear
Date

Form for Voluntary Respirator Use - Appendix D
Name:

Document Upload

Please take a photo of requested documents below to include in employment application. Please make sure that they are clear and legible photos. If they are not, HR may ask you to resend them.
Driver License
Social Security Card
OSHA Card
First Aid Training - With Expiration
Other Trainings / Documents Applicable
Other Trainings / Documents Applicable

New Employee Safety Orientation Checklist

During weather delays or supervisor approved time, IPC needs you to complete the following Safety Modules. Please create an account on our website.
Once your account has been created, please let Andrea Avis at aavis@ip-co.net know so that she can grant you access to the following training:
1. IPC Safety Expectations
2. Hazard Communications / MSDS
3. IPC Lockout Tagout policy and procedures
4. Electrical Safety
5. Ladder Safety
6. Personal Protective Equipment (PPE)
7. Hand and Power Tools
8. Fall Protection
9. Housekeeping
10. Proper lifting procedures including the Stretch N Flex process
Once you have submitted this application you will be prompted to fill out a CDL application, if you have a CDL. Or continue to the website to create an account for the above-mentioned trainings.

Click the link to continue to the website, create an account, call or email Andrea in HR at 308-221-6267 or aavis@ip-co.net. Once she approves your account you will be able to access all the trainings and forms needed!
Should be Empty:

Employment Packet

Applicant Information

Education

References

Previous Employment

Military Service

Disclaimer and Signature

Employee Safety Handbook Acknowledgment

DRUG & ALCOHOL TESTING CONSENT FORM

DRIVER RECORD SCREENING DISCLOSURE

8850 Pre-Screening Notice and Certification Request for the Work Opportunity Credit

Form I-9 Employment Eligibility Verification

Preparer and/or Translator Certification for Section 1

W-4

W-4N

Employee Direct Deposit Authorization

Emergency Contact Information

Employee Acknowledgment Form

Pre- Existing Injuries Disclosure Form

Cell Phone Use Policy

IPC Vehicle Use Agreement

Form for Voluntary Respirator Use - Appendix D

Document Upload

New Employee Safety Orientation Checklist