Wire Guard Application - All Utility Support Services

Full Name*

First Middle Last

Date*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Cell Phone*

Vehicle To Be Used (Year, Make, & Model)*

How Did You Hear About Us? (Referral)*

Are you a citizen of the United States?*

Yes
No

If no, are you authorized to work in the U.S.?*

Yes
No

Are you at least 18 years or older?*

Yes
No

Do you have a Smart Phone?*

Yes
No

Can you travel for multi-day assignments?*

Yes
No

Can you work a 12-16 hour day shift?*

Yes
No

Can you work a 12-16 night shift?*

Yes
No

Where are you located?*

Orange & Rockland Service Territory
Central Hudson Service Territory
Other

Skills for Administrators/Coordinators

Are you skilled at Word documents?*

Yes
No

Can you use Excel Spreadsheets?*

Yes
No

Can you use GPS on your smartphone?*

Yes
No

Can you use Email?*

Yes
No

Prior Work Experience:

List*

From	To	Company	Position

Driver’s License Information

State:*

Expiration Date:*

Consent To Release Records

DRIVER NAME*

(AS SHOWN ON LICENSE)

Driver's License #*

DOB:*

By signing below, I voluntarily give consent to the New York State Department of Motor Vehicle (NYSDMV) to release the following record(s), including personal information within my driver license file. I request the record(s) indicated by my signature below to be released by the NYSDMV, their agents and employees, to All Bright Support Services:

DRIVER'S SIGNATURE OF CONSENT:

Emergency Contact Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone**

Email*

Relationship to Applicant:*

Disclaimer and Signature

Disclaimer and Signature Please read carefully before signing.

All Utility Support Services, Inc. is an equal opportunity employer. All Utility Support Services LLC does not discriminate in employment on account of race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service.

I understand that neither the completion of this application nor any other part of my consideration for deployment establishes any obligation for All Utility Support Services, Inc. to contract with me. If I am deployed, I understand that either All Utility Support Services LLC or I can terminate my deployment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of All Utility Support Services LLC has the authority to make any assurance to the contrary.

I attest with my signature below that I have given to All Utility Support Services LLC true and complete information on this application. No requested information has been concealed. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal. A valid license and driving record will be checked.

The content in this application is an understanding and agreement of terms by and between All Utility Support Services LLC (AUSS), with offices at 6 Old Lake Road, Valley Cottage, NY 10989, and the Site Safety Representative (Wire Guard) which becomes effective upon signing on the date below.

1. Term: AUSS will retain Service Provider, and Service Provider will accept such retention, commencing as of the effective date of this Agreement and continuing until terminated by either party, or until the services provided are complete and Service Provider has been totally reimbursed.

2. Description of Services Provided: Site Safety Representative Service Provider will, using their own vehicle and cell phone, be assigned to safe guard barricaded, but energized, down wires and discourage the general public from entering the barricaded area, while keeping safe distance from the energized areas. Daily assignments will be no less than 2 hours and could be as much as 16 hours. Downed wires are safeguarded 24/7 until a repair crew arrives to make the area safe. The site safety representative is not to leave the site unguarded and should call for relief if necessary. Shifts will normally be 12-14 hours. Personal Protective Safety equipment will be provided, as required.

3. Compensation and Insurance: AUSS will pay Service Provider as compensation of the published hourly rate for Site Safety Representative services from the time of reporting for assignment to release; the reporting and release times may vary daily depending upon client needs.

In addition, the Service Provider will be reimbursed for use of their vehicle for Wire Guarding if dispatched to a site during the work shift. Payment for services rendered and approved expenses will be made within thirty (30) days of the completion of a client deployment.

4. Notice: Any notice to required or permitted by the terms of this Agreement shall be given by registered mail, prepaid and properly addressed as follows:

If to All Utility Support Services: All Utility Support Services LLC

6 Old Lake Road Valley Cottage, NY 10989

If to Site Safety Representative: Name:________________________________ Street:________________________________ City:__________________State:__________Zip:__________ Other Information Required Phone: Mobile: ___________________________Home:_________________________ Email Address:_________________________________@______________ Driver’s License: State_________ #__________________________Expiration____/____/_____ Vehicle Make/Model:______________________State:_______ Plate#:_____________ Date of Birth: ____/____/____ Are you a citizen of the US? YES NO If NO, are you authorized to work in the US? YES NO Emergency Contact: ____________________________________ Relationship:__________________ Address (if different than above): _______________________________________________________ Contact Phone: Mobile:_________________________ Home:_______________________ Any such notice shall be deemed to have been given when received.

5. Survival and Termination: (a) This Agreement may be terminated by either party upon thirty (30) days written notice to the other party. (b) This Agreement may be terminated by a non-breaching party, in addition to any other remedy, for breach of any term of this Agreement, upon written notice to the breaching party; upon which event all rights of the breaching party shall terminate.

6. Entire Agreement: This Agreement is the entire agreement of the parties relating to the subject matter hereof, and supersedes all prior and contemporaneous negotiations, correspondence, understandings, and agreements of the parties relating to the subject matter hereof. It may be amended only by an agreement in writing, signed by both parties.

7. Not an Employee: Service Provider is an independent contractor and is not an employee or agent of AUSS. Service Provider shall be entitled to no benefits or compensation from AUSS except as set forth in this Agreement and shall in no event be entitled to any fringe benefits payable to any employees of AUSS. Service Provider shall be solely responsible for the payment of all taxes due on the income received for the services provided under this Agreement.

Signature*

Date*