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Driver's Application for Employment

Applicant Name:

Date of Application:
April 15, 2024

Company: Schiffman Trucking, Inc.

Address: PO Box 260167, Plano, TX 75026

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.)

I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of my employment, I understand that false or misleading information given in my application of interview(s) may result in discharge. I understand, also, that I am require to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous employers may be used, and those employers(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

Review information provided by previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employers(s) and I cannot agree on the accuracy of the Information.

FOR COMPANY USE

PROCESS RECORD

Applicant Hired:	Rejected:
Date Employed:	Point Employed:
Department:	Classification:

TERMINATION OF EMPLOYMENT

Date Terminated:	Department Released From:
Dismissed Voluntarily Quit Other	Termination Report Placed In File:
Supervisor:

APPLICANT TO COMPLETE
(answer all questions)

Position(s) Applied for:

Last Name:

First Name:

Middle Name:

Social Security No:

List your addresses of residency for the past 3 years:

Current Address

Street:		City:
State:	Zip Code:	Phone:	How Long?

Previous Addresses

Street:	City:	State & Zip Code:	How Long?
Street:	City:	State & Zip Code:	How Long?
Street:	City:	State & Zip Code:	How Long?

Do you have the legal right to work in the United States? YesNo
Date of Birth:		Can you provide proof of age? YesNo
Have you worked for this company before? YesNo		If yes, where?
Dates From:	To:	Rate of Pay:	Position:
Reason(s) for Leaving:
Are you now employed? YesNo		If not, how long since leaving last employment?
Who referred you?		Rate of pay expected:
Have you ever been bonded? YesNo		If Yes, Name of bonding company:
Have you ever been convicted to a felony? YesNo
If yes, explain if you wish.

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

EMPLOYER		DATE
Name:		From: To:
Address:		Position Held:
City:	State:	Zip:	Salary / Wage:
Contact Person	Phone Number:	Reason for Leaving:
Were you subject to the FMCSRs while employed? YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug And Alcohol Testing Requirements of 49 CFR PART 40? YesNo

EMPLOYER		DATE
Name:		From: To:
Address:		Position Held:
City:	State:	Zip:	Salary / Wage:
Contact Person	Phone Number:	Reason for Leaving:
Were you subject to the FMCSRs while employed? YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug And Alcohol Testing Requirements of 49 CFR PART 40? YesNo

EMPLOYER		DATE
NAME:		From: To:
Address:		Position Held:
City:	State:	Zip:	Salary / Wage:
Contact Person:	Phone Number:	Reason for Leaving:
Were you subject to the FMCSRs while employed? YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug And Alcohol Testing Requirements of 49 CFR PART 40? YesNo

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

* The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in intestate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR or 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), or (3)is of any size and is used to transport hazardous materials in a quantity requiring placarding.

ACCIDENT RECORD

For Past 3 years or more (ATTACH SHEET IF MORE SPACE IS NEEDED). If none, write none.

	DATES	NATURE OF ACCIDENT (HEAD-ON, REAR-END,UPSET, ETC.)	FATALITIES	INJURIES	HAZARDOUS MATERIAL SPILL
LAST ACCIDENT
NEXT PREVIOUS
NEXT PREVIOUS

TRAFFIC CONVICTIONS

And forfeitures for the past 3 years (OTHER THAN PARKING VIOLATIONS). If none, write none.

LOCATION	DATE	CHARGE	PENALTY

EXPERIENCE & QUALIFICATIONS - DRIVER

List all driver licenses or permits held in the past 3 years

DRIVER LINCENSES	STATE	LICENSE NO.	EXPIRATION DATE

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

YesNo

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

YesNo

If the answer to both A and B is "Yes", please give details:

DRIVING EXPERIENCE

Check Yes or No.

CLASS OF EQUIPMENT	CHECK TYPE OF EQUIPMENT	DATES
Straight Truck YesNo	Van Tank Flat Dump Refer	From: To:
Tractor & Semi Trailer YesNo	Van Tank Flat Dump Refer	From: To:
Tractor-Two Trailers YesNo	Van Tank Flat Dump Refer	From: To:
Tractor-Three Trailers YesNo	Van Tank Flat Dump Refer	From:
Motorcoach-School Bus More than 8 passengers YesNo		From: To:
Motorcoach-School Bus More than 15 passengers YesNo		From:

List States Operated in for the last five years:

Show Special Courses or Training that will help you as a driver:

EXPERIENCE AND QUALIFICATIONS - OTHER

Show any trucking, transportation, or other experience that may help in your work for this company:

List courses and other training other than shown elsewhere in this application:

List special equipment or technical materials you can work with (Other than those already shown)

EDUCATION

Check Highest Grade Completed:
12345678

High School:
1234

College:
1234

To be read and signed by applicant

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.

Company Name: Schiffman Trucking, Inc.

Date: April 15, 2024

Social Security Number:

Leave this empty:

Your legal name

Your email address

Timestamp

Audit

January 28, 2022 6:39 am CDT

Driver's Application for Employment Uploaded by Lynn Moore Schiffman - lynn@schiffmantrucking.com IP 49.150.208.88