Driver Application of Employment

Driver Application of Employment

Please fill out the following form:

If you prefer not to submit your application online, you can also print
this document, fill it out, then mail or fax it to:
OFC-Schmidt Transportation
108 East Bay Rd.
Plattsmouth, NE 68048

Or Fax it to: 1-402-298-8567

Feel free to call with questions! 1-800-755-4582 x. 307

General Information

Name: Last		First

Former Name:

Social Security#:

- -

Birth Date: / /

Email:

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:

City:

State:

Zip:

How long at this address?

Driver's License Information:

License #1:

State:

No:

Class:

Endorsements:

Expiration Date: / /

License #2:

State:

No:

Class:

Endorsements:

Expiration Date: / /

Employment Status and Record

Please note: We pay for a Hazmat background check (Hazmat not needed to start,
but we will pay for you to get the endorsement within 60 days of hire).

How much class A experience do you have?

Regions driven in:

NW SW NE SE Midwest Canada

Have you ever been convicted of/or have a pending felony?:

yes no

If yes, when?:

Have you ever been convicted of/or have a pending DWI/DUI?

yes no

If yes, when?:

Have you ever tested positive on alcohol/controlled substance test?

yes no

If yes, when?:

Are you authorized to work in the United States?

yes no

Are you able to pass a two year DOT physical?

yes no

Do you take any medications that could affect your driving?

yes no

Has your license ever been denied, revoked or suspended?

yes no

Have you served in the U.S. Armed Forces?

yes no

Have you worked or applied for work at OFC-Schmidt Transportation?

yes no

If yes, when?:

How did you hear about us?:

From a driver?:

yes no

If so, what was his/ner 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?:

Previous Employment:

From:

To:

Company Name:

Phone:

Street Address:

City:

State:

Zip:

Position:

Reason for Leaving:

Ending Pay:

Previous Employment:

From:

To:

Company Name:

Phone:

Street Address:

City:

State:

Zip:

Position:

Reason for Leaving:

Ending Pay:

Previous Employment:

From:

To:

Company Name:

Phone:

Street Address:

City:

State:

Zip:

Position:

Reason for Leaving:

Ending Pay:

Previous Employment:

From:

To:

Company Name:

Phone:

Street Address:

City:

State:

Zip:

Position:

Reason for Leaving:

Ending Pay:

Previous Employment:

From:

To:

Company Name:

Phone:

Street Address:

City:

State:

Zip:

Position:

Reason for Leaving:

Ending Pay:

Previous Employment:

From:

To:

Company Name:

Phone:

Street Address:

City:

State:

Zip:

Position:

Reason for Leaving:

Ending Pay:

Driving Record

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:

Please list the DATE (month and year) for each accident, and then describe each accident—please include whether it was PERSONAL OR ON-THE-JOB, if it involved a COMMERCIAL VEHICLE, the AMOUNT ($) of damage, whether the accident was PREVENTABLE or not, and what INJURIES OR FATALITIES were involved.

Accident Description:

Date:

Type of accident?:

personal on-the-job

Type of vehicle?:

commercial personal

Amount of damage:

Was the accident preventable?:

yes no

Describe any injuries/fatalities:

Accident Description:

Date:

Type of accident?:

personal on-the-job

Type of vehicle?:

commercial personal

Amount of damage:

Was the accident preventable?:

yes no

Describe any injuries/fatalities:

Accident Description:

Date:

Type of accident?:

personal on-the-job

Type of vehicle?:

commercial personal

Amount of damage:

Was the accident preventable?:

yes no

Describe any injuries/fatalities:

Accident Description:

Date:

Type of accident?:

personal on-the-job

Type of vehicle?:

commercial personal

Amount of damage:

Was the accident preventable?:

yes no

Describe any injuries/fatalities:

Education and References

Driving School:

Phone:

Start Date:

End Date:

School Address:

City:

State:

Zip:

Check highest grade completed:

10 11 12

Years beyond high school:

1 2 3 4 5 6 7 8

Technical/Trade Schools attended:

When:

Courses, seminars or other pertinent training:

When:

Personal References (Do not use relatives or former employers):

Name:	Occupation:	Phone Number:

In case of emergency:

Contact #1:

Name:

Relationship:

City:

State:

Phone:

Contact #2:

Name:

Relationship:

City:

State:

Phone:

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.

Digital 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.

Comments:

Digital Signature:

Date:

Social Security #:

- -

After submitting, please call 800-755-4582 ext 307 during
business hours to confirm receipt.