Driver Application of Employment
Please PRINT this document, fill it out, then mail or fax it to:
OFC-Schmidt Transportation
108 East Bay Rd.
Plattsmouth, NE 68048
1-402-298-8567 (FAX)
And feel free to call with questions! 1-800-755-4582
General Information
Please print in ink.
Name: Last_________________________________ First______________________________ Middle______________
Former Name:______________________ Social Security #:________ - _____ -__________ Birth Date:____/___/_____
Home Phone: ( _________ ) _________ - __________ Contact Phone ( _________ ) ___________ - _____________
Current Address:___________________________________City___________________ State______ Zip____________
How long at this address?_________________ Past address if less than five years at present address:
Past Address:______________________________________________________
How long at this address?___________
Driver’s License Information
State - License - Number - Class - Endorsements - Expiration Date
1._______________________________________________________________________________________/_____/____
2._______________________________________________________________________________________/_____/____
Please note: Hazardous Material Endorsement is a necessary requirement of OFC-Schmidt Transportation
Over-the-Road Experience in the last five years q 1 or more years q less than one year
Regions driven in: q NW q SW q NE q SE q Midwest q Canada
Have you ever been convicted of/or have a pending felony? q Yes q No If yes, when?__________
Have you ever been convicted of/or have a pending DWI/DUI? q Yes q No If yes, when?__________
(If yes, please give details in traffic violation information, page 3)
Have you ever tested positive on alcohol/controlled substance test? q Yes q No If yes, when?__________
Are you authorized to work in the United States? q Yes q No
Are you able to pass a two year DOT physical? q Yes q No
Do you take any medications that could affect your driving? q Yes q No
Has your license ever been denied, revoked or suspended? q Yes q No
(If yes, please explain in driver’s license information)
Have you served in the U.S. Armed Forces? q Yes q No
Did you serve during the Vietnam Era (1963 to 1974)? ? q Yes q No
Have you ever worked Å / applied for work Å at OFC-Schmidt Transportation ?
If yes, when?_____________
How did you hear about us? _________________ Driver q Yes q No Driver Name__________
Employment History
A complete record of employment for the past ten years is necessary for your application to be processed. Please list your present employer first. All periods of time must be accounted for during this ten-year period, including military service, self-employment, non-driving positions and periods of unemployment. Provide complete address and phone numbers, including area codes and zip codes.
DATE AVAILABLE FOR WORK:______________________________
From:__________To:__________ Company Name:__________________________________________________________
Phone:( ______ ) _____________ Street Address:___________________________________________________________
Position:____________________ City:___________________________________State:_______________Zip:_________
Reason For Leaving:______________________________________________________ Ending Pay: __________________
From:__________To:__________ Company Name:__________________________________________________________
Phone:( ______ ) _____________ Street Address:___________________________________________________________
Position:____________________ City:___________________________________State:_______________Zip:_________
Reason For Leaving:______________________________________________________ Ending Pay: __________________
From:__________To:__________ Company Name:__________________________________________________________
Phone:( ______ ) _____________ Street Address:___________________________________________________________
Position:____________________ City:___________________________________State:_______________Zip:_________
Reason For Leaving:______________________________________________________ Ending Pay: __________________
From:__________To:__________ Company Name:__________________________________________________________
Phone:( ______ ) _____________ Street Address:___________________________________________________________
Position:____________________ City:___________________________________State:_______________Zip:_________
Reason For Leaving:______________________________________________________ Ending Pay: __________________
From:__________To:__________ Company Name:__________________________________________________________
Phone:( ______ ) _____________ Street Address:___________________________________________________________
Position:____________________ City:___________________________________State:_______________Zip:_________
Reason For Leaving:______________________________________________________ Ending Pay: __________________
From:__________To:__________ Company Name:__________________________________________________________
Phone:( ______ ) _____________ Street Address:___________________________________________________________
Position:____________________ City:___________________________________State:_______________Zip:_________
Reason For Leaving:______________________________________________________ Ending Pay: __________________
Employment History Cont.
From:__________To:__________ Company Name:__________________________________________________________
Phone:( ______ ) _____________ Street Address:___________________________________________________________
Position:____________________ City:___________________________________State:_______________Zip:_________
Reason For Leaving:______________________________________________________ Ending Pay: __________________
From:__________To:__________ Company Name:__________________________________________________________
Phone:( ______ ) _____________ Street Address:___________________________________________________________
Position:____________________ City:___________________________________State:_______________Zip:_________
Reason For Leaving:______________________________________________________ Ending Pay: __________________
Please provide us with traffic violations and accident information for the last five years. Any deletions or omissions will be sufficient reason for denial of your application.
Traffic Violations
Date State Type of Violation (ie. speeding - 10 miles
over) Points or Penalty
____/____/_______________________________________________________________________________________
____/____/_______________________________________________________________________________________
____/____/_______________________________________________________________________________________
Accident Information
Date Personal or Nature of Accident Preventable Injuries Fatalities Amount
Commercial Vehicle Non-Preventable
/ /
Details:
/ /
Details:
/ /
Details:
/ /
Details:
Education
Driving School:____________________________________ Phone #:( ______ )_____________ Start Date:____________
End Date:_____________
Address:_________________________________________City_____________________ State_______ Zip___________
Check highest grade completed: q 10 q 11 q 12
Years beyond high school q 1 q 2 q 3 q 4 q 5 q 6 q 7 q 8
Technical/Trade Schools attended:_____________________________________________ When:_____________________
Courses, seminars or other pertinent training:____________________________________ When:_____________________
Personal References (Do not use relatives or former employers):
1. __________________________________ _________________________________ ( _______ ) ______________
Name Occupation Phone Number
2. __________________________________ _________________________________ ( _______ ) ______________
Name Occupation Phone Number
3. __________________________________ _________________________________ ( _______ ) ______________
Name Occupation Phone Number
In case of emergency:
__________________________________ ___________________________________ ( _______ ) ______________
Name & Relationship City, State Phone Number
__________________________________ ___________________________________ ( _______ ) ______________
Name & Relationship City, State Phone Number
OFC-Schmidt Transportation is an equal opportunity employer.
This certifies that I, personally, accurately and truthfully completed this application. I understand that any omission or misrepresentation is "falsification" and may result in refusal of or separation from employment. I hereby authorize OFC-Schmidt Transportation, to make a complete investigation of my background including but not limited to: contacting personal references, current and past employers, and DAC services to confirm information I provided but not limited to information required by 391.23 of the Motor Carrier Safety Regulations and investigate previous employer Alcohol & Controlled Substance Testing in accordance with Section 382.405 (F&H) and Section 382.413 (A thru G) of the Code of Federal Regulations and hold previous employers harmless of all liability from release of said information. It is agreed and understood that this application for employment in no way obligates the employer to employ the applicant.
______________________________________________________ __________________________________
Signature / Date
Disclosure and Release
In connection with my application for employment (including contract for services) with you, I understand that consumer reports which may contain public record information may be requested from DAC Services, Tulsa, Oklahoma. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers’ compensation claims, credit, bankruptcy proceedings, criminal records, etc. from federal, state and other agencies which maintain such records; as well as information from DAC concerning previous driving record requests made by others from such state agencies, and state provided driving records.
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY DAC TO FURNISH THE ABOVE-MENTIONED INFORMATION.
I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which DAC has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from DAC, and I agree that such information which DAC has or obtains, and my employment history with you if I am hired, will be supplied by DAC to other companies which subscribe to DAC services.
I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.
___________________________________ ______________________________
Print Name / Social Security #
___________________________________ ___________________________________
Signature of Driver / Date