THE INDUSTRIAL ELECTRIC COMPANY OF CHARLOTTE

THE INDUSTRIAL ELECTRIC COMPANY OF CHARLOTTE – EMPLOYMENT APPLICATION

APPLICANT INFORMATION
Today's Date

MonthDayYear
Name

First NameMiddle NameLast Name
*Address

Street Address, Apartment/Unit #

Apartment/Unit #

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Email
Date Available

MonthDayYear
Social Security #
Position Applied for
Desired Salary
*If at the above address less than 3 years, list below all residences for the past 3 years. Attach a separate sheet if necessary.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Address

Street Address

Street Address Line 2

CityState

Zip Code
Are you a citizen of the United States?

YesNo
If no, are you authorized to work in the US?

YesNo
Have you ever worked for this company?

YesNo
If so, when?
Have you ever been convicted of a felony?

YesNo
If yes, explain

EDUCATION
High School
Address
Years Attended: From YYYY to YYYY
Did you graduate?

YesNo
Degree
College
Address
Years Attended: From YYYY to YYYY
Did you graduate?

YesNo
Degree
Other
Address
Years Attended: From YYYY to YYYY
Did you graduate?

YesNo
Degree

MILITARY SERVICE
Branch
Years Served: From YYYY to YYYY
Rank at Discharge
Type of Discharge
If other than honorable, explain

REFERENCES
PLEASE LIST THREE PROFESSIONAL REFERENCES
Name

First NameLast Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Name

First NameLast Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Name

First NameLast Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code

PREVIOUS EMPLOYMENT
Company
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Years Employed: From YYYY to YYYY
Reason for leaving
May we contact your previous supervisor for a reference?

YesNo
Company
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Years Employed: From YYYY to YYYY
Reason for leaving
May we contact your previous supervisor for a reference?

YesNo
Company
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Years Employed: From YYYY to YYYY
Reason for leaving
May we contact your previous supervisor for a reference?

YesNo

DRIVER EXPERIENCE & QUALIFICATION
ANSWER THE QUESTIONS IN THIS SECTION ONLY IF APPLYING FOR DRIVER POSITION

The US Department of Transportation requires that driver applicants state their date of birth (§391.21(b)(2))
Date of Birth

MonthDayYear
Social Security #

Driver's licenses held in the past 3 years must be shown.

	State	License No.	Class	Endorsement(s)	Expiration Date
1
2
3

A. Have you ever been denied a licenses, permit or privilege to operate a motor vehicle?

YesNo
B. Has any license, permit or privilege ever been suspended or revoked?

YesNo
C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?

YesNo
If you answered “YES” to A, B or C - Attach a statement giving details.

Accident review for past 3 years (attach a separate sheet if more space is needed)

	Dates	Nature of Accident (Head-on, Rear-end, Overturn, etc.)	Fatalities	Injuries
Last Accident
Previous Accident
Previous Accident

Traffic convictions & forfeitures for past 3 years otherthan parking violations

	Location	Date	Charge	Penalty
1
2
3

APPLICATION SIGNATURE
I certify that I have read and understood all of this employment application. It is agreed and understood that the employer or his agents may investigate my background to ascertain any and all information of concern to my employment history, whether same is of record or not, and I release employers and other persons named herein from all liability for any damages on account of furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job. I also understand that if offered a job, it may be conditioned on the results a physical examination and/or a drug test.

I further certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with the employer and for no other reason.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Lay 91-508, I have been told that this investigation may include and investigate Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

If hired, I agree to abide by all the rules and policies of the employer.

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.
Date

MonthDayYear
Date
Applicant's Signature*

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Cover Letter

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Resume

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Additional Uploads as Needed

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FAIR CREDIT REPORTING ACT DISCLOSURE & AUTHORIZATION
DISCLOSURE

In considering you as an applicant for employment or as a current employee, we may choose to secure and use information contained in either a consumer report or investigative consumer report about you obtained from a consumer reporting agency when: (1) considering your application for employment (2) making a decision whether to offer you employment, (3) deciding whether to continue your employment or (4) making other employment-related decisions directly affecting you.

For explanation purposes, a "consumer reporting agency" is a person or business that, on a cooperative nonprofit basis, or for monetary fees or dues, regularly assembles or evaluates consumer credit information or other information on consumers for a person who has a legitimate business need for the information or intends to use the information for employment purposes.

A "consumer report" means any written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing your eligibility for employment purposes.

An "investigative consumer report" means a consumer report or portion thereof in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your neighbors, friends, or associates reported on or with others with whom you are acquainted or who may have knowledge concerning any such items of information.

In the event an investigative consumer report is prepared, you may request additional disclosures regarding the nature and scope of the investigation requested as well as a written summary of your rights under the Fair Credit Reporting Act.
AUTHORIZATION

By your signature below, you hereby authorize us to obtain a consumer report and/or an investigative report about you in order to consider you for employment. If hired, this authorization shall remain on file and shall serve as an ongoing authorization for us to procure consumer reports at any time during the employment period.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature*

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The Industrial Electric Company of Charlotte Consent, Authorization and Release of Liability for Drug Testing
I understand and agree that in accordance with The Industrial Electric Company of Charlotte’s policy of providing and maintaining a safe and healthy working environment for all employees, I voluntarily agree to undergo a drug test. I understand that, as a condition of employment, The Industrial Electric Company of Charlotte Substance Abuse Policy requires drug urine tests of applicants selected for employment and employees for the purpose of evaluating mental and physical suitability for employment in positions as specified in the Company’s Substance Abuse Policy.

I hereby give my permission for Concentra and its agents, to obtain a urine specimen, (or blood sample when alcohol or drug testing is required and breathalyzer or urine test is impractical) from me now and anytime during my employment, including post-accident situations when an additional consent may be impractical or unobtainable. I also understand that this is not a diagnostic examination designed to detect hidden performance effectiveness and possible safety risks to the company, and to me, which might arise as a result of such employment.

I understand that a positive test result will disqualify me from consideration for employment, or at later time, may result in my termination from employment. I fully understand and accept the condition that any false answers or willful omissions made by me will be sufficient grounds for my discharge, irrespective of when the false answers or omissions are discovered.

I understand and agree that neither The Industrial Electric Company of Charlotte, Concentra, the examining physicians, medical personnel or other staff shall be liable for injury of suffering experienced by me as a result of a physical or mental infirmities, disease, or conditions not detected during the course of such testing or for failure to direct me to a specialist for treatment. I understand that all drug and alcohol testing will be conducted at a laboratory certified by the National Institute on Drug Abuse or other appropriate facility approved by the company.

I authorize the release of my test results to the Substance Abuse Policy Administrator of The Industrial Electric Company of Charlotte.
Applicant Full Name

First NameMiddle NameLast Name
Social Security #
Date of Birth

MonthDayYear
Applicant Signature*

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Date

MonthDayYear
Witness Signature

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Date

MonthDayYear
Should be Empty:

THE INDUSTRIAL ELECTRIC COMPANY OF CHARLOTTE – EMPLOYMENT APPLICATION

FAIR CREDIT REPORTING ACT DISCLOSURE & AUTHORIZATION

Authorization to Obtain Records and Other Information for Employment Purposes

The Industrial Electric Company of Charlotte Consent, Authorization and Release of Liability for Drug Testing