ICCI,Your Transporation Partener with the Power to Go the Distance.

Customer

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1.541.734.9141
(Local)

1.800.422.8785
(Long Distance)

AGENT APPLICATION

* Last name:			* First:			Middle:
Mailing address: City: State: Zip:

Home phone:

Cell phone: * E-mail:


Are you currently employed? Yes No

Do you have experience in the transportation industry? Yes No

Please describe:
Date available to start:
Where is your business going to be located? HomeOffice building

Why do you want to be an agent for ICCI?

What are your income expectations?

What are your expectations of ICCI if you are to become an agent?

EDUCATION AND FORMAL TRAINING

Do you have a high school diploma? Yes

If yes…list school and location:

List highest grade completed:

Do you have a GED? Yes No

SCHOOLS ATTENDED AFTER HIGH SCHOOL OR SPECIAL TRAINING RECEIVED

College	Location	# years completed	Major	Degree

Business or trade school	Location	Length of course	Subject	Completed

EMPLOYMENT HISTORY
List your work history in chronological order, with current or most recent job first.
List each job separately, even if it is in the same organization. Include military, unpaid, and volunteer work.

Current or last employer:					Type of business:

Address:
Job Title:					Salary:
Employment dates - From: To: Total years in position:
Reason for leaving:
Supervisor's name and phone number:
May we contact for reference? Yes No Later
Summarize nature of work performed and responsibilities:

Employer					Type of business:

Address:
Job Title:					Salary:
Employment dates - From: To: Total years in position:
Reason for leaving:
Supervisor's name and phone number:
May we contact for reference? Yes No Later
Summarize nature of work performed and responsibilities:

Employer					Type of business:

Address:
Job Title:					Salary:
Employment dates- From: To: Total years in position:
Reason for leaving:
Supervisor's name and phone number:
May we contact for reference? Yes No Later
Summarize nature of work performed and responsibilities:

Employer					Type of business:

Address:
Job Title:					Salary:
Employment dates- From: To: Total years in position:
Reason for leaving:
Supervisor's name and phone number:
May we contact for reference? Yes No Later
Summarize nature of work performed and responsibilities:

Employer					Type of business:

Address:
Job Title:					Salary:
Employment dates- From: To: Total years in position:
Reason for leaving:
Supervisor's name and phone number:
May we contact for reference? Yes No Later
Summarize nature of work performed and responsibilities:

Employer					Type of business:

Address:
Job Title:					Salary:
Employment dates- From: To: Total years in position:
Reason for leaving:
Supervisor's name and phone number:
May we contact for reference? Yes No Later
Summarize nature of work performed and responsibilities:

COMPUTER SKILLS, TRAINING AND EXPERIENCE

Formal computer classes and training

List computer hardware and software you have used

High skill

Regular use

Basic knowledge

Do you speak a foreign language?

Yes

Language

REFERENCES

Please list three non-relatives who are familiar with your qualifications and actual work history and abilities

Name

Company name and title

Phone

Occupation/Title

Please read carefully before submitting

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any repect will be sufficient cause to cancel further consideration of this application, or immediate discharge whenever it is discovered.

I authorize ICCI, its representatives, employees or agents to contact and obtain information from all references(personal and professional), employers, licensing authorities and educational institutions to verify the accuracy of information provided by me in the application, resume, or job interview. I hereby release ICCI, as well as any other agency, school, individual, or company contacted from any liability or damage which may result from obtaining the information requested.

I understand that ICCI does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration.

I understand this application remains current for 30 days. At the conclusion of that time, if I have not heard from ICCI and still wish to be considered for employment, it will be necessary to reapply and fill out another application

If I am hired, I understand I am free to resign at any time, with or without cause and without prior notice, and ICCI reserves the same right to terminate my employment at any time with or without cause, and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for any specified period of time.

If I am hired, I understand I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9.

By clicking on submit button below I have read and understand the above terms

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