D.M.T. Services, Inc.

Application for Employment

Please Note:

If you have a resume you would like to send instead of filling this out, then please email to hr@dmtservicesinc.com

This application form was designed for use by persons applying for various types of positions -- clerical, professional, technical, and administrative. Please answer the questions to the best of your ability. All information will be treated confidentially.

ALCOHOL & DRUG TESTING REQUIRED.

*** Applicants Must Live Within A 60 Mile Radius Of

Siloam Springs, AR or Ft. Smith, AR ***

First Name:
Last Name:
Federal D.O.T. regulations require you to list all residences held for the previous three years.
Address:
Address:
City:
State:
Zip:
Home Phone:
Business Phone:
Use this space for additional addresses:

How were you referred to us?

Newspaper Ad	School	On My Own
Current Employee	Agency	Other

Name of referral source:

TYPE OF WORK DESIRED

Indicate the position for which you are applying:

Do you wish to work:

Full Time

Part Time

Temporary

If part time, specify hours or days:

What is your minimum weekly salary requirement?
Mileage Requirement?
Date available for work:
Do you have any commitments to another employer that might affect your employment with us?

NOTICE
Answer all questions that apply to you and the job you are applying for.

EDUCATIONAL DATA

School	Print Name, Number, Street, City, State and Zip Code for each School Listing	No. of Years Completed	Degree, Major, or Type of Course
High School
College
Graduate School
Trade, Bus., Night, or Corres.
Other

MILITARY EXPERIENCE

Were you in the U.S. Armed Forces? Yes No

If yes, what branch?
Dates of duty: From: To: Rank at Separation:
Briefly describe your duties:

EMPLOYMENT HISTORY

Any person applying for a job as a commercial vehicle driver must inform the prospective employer of all previous employment as the driver of a commercial vehicle for the past 10 years, in addition to any other required information about the applicant's employment history.

List present employer or most recent employer first.

May we contact these employers? Yes No

Employer:			Employed From Mo./Yr: To Mo./Yr:	Supervisor's Name:
Address:
Telephone:				Your Job Title:
Your Salary		Duties:
Start	End

Reason For Leaving:

Employer:			Employed From Mo./Yr: To Mo./Yr:	Supervisor's Name:
Address:
Telephone:				Your Job Title:
Your Salary		Duties:
Start	End

Reason For Leaving:

Employer:			Employed From Mo./Yr: To Mo./Yr:	Supervisor's Name:
Address:
Telephone:				Your Job Title:
Your Salary		Duties:
Start	End

Reason For Leaving:

Employer:			Employed From Mo./Yr: To Mo./Yr:	Supervisor's Name:
Address:
Telephone:				Your Job Title:
Your Salary		Duties:
Start	End

Reason For Leaving:

If you need more space to cover your 10-year driving record, use the box below:

EXPERIENCE AND QUALIFICATIONS -- DRIVER
(Answer only if applying for driving position)

Date of Birth:

DRIVER'S LICENSES (any held in past three years must be shown)	State	License No.	Type	Exp. Date

A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Yes No

B. Has any license, permit, or privilege ever been suspended or revoked? Yes No

C. Have you ever been disqualified subject to section 391 of the Federal Motor Carrier Safety Regulations? Yes No

If the answer to either A, B, or C is yes, please give details:

DRIVING EXPERIENCE

Class of Equipment	Type of Equipment (Van, Tank, Flat, Etc.)	Dates		Approx. No. of Miles (total)
Class of Equipment	Type of Equipment (Van, Tank, Flat, Etc.)	From	To	Approx. No. of Miles (total)
Straight Truck
Tractor And Semi-Trailer
Tractor - Two Trailers
Other

List states operated in for the last five years:

Show special courses or training that will help you as a driver:

Which safe driving awards do you hold and from whom?:

ACCIDENT REVIEW FOR PAST 3 YEARS

Dates	Nature of Accident (Head-On, Rear-End, Upset, Etc.)	Fatalities	Injuries
Last Accident
Next Previous
Next Previous
Next Previous

Traffic convictions and forfeitures for the past 3 years (other than parking violations):

Location	Date	Charge	Penalty

Date of last DOT Physical Examination:

I hereby authorize release of any driving record to D.M.T. Services, Inc. This is for employment purposes on a "new hire" and shall include all convictions on my record from all states.

GENERAL INFORMATION

Are you a U.S. Citizen? Yes No

If no, what type of visa do you hold?

Are you willing to undergo a pre-employment physical exam? Yes No

Have you ever been convicted of a criminal offense? Yes No

Nature:

(An affirmative answer will not automatically disqualify you.)

Have you previously applied for employment here? Yes No

If yes, when?

Are any of your relatives employed here? Yes No

If yes, please list name and department:

REFERENCES (Not employers or relatives -- At least three)

Name and Address	Occupation	Phone

Person to be notified in case of Emergency:

First Name:
Last Name:
Address:
City:
State:
Zip:
Phone:

Additional supportive information:

RELEASE FOR ALL RECORDS

I hereby authorize your company/organization to release to D.M.T. Services, Inc. all records of my employment...

DRIVER RELEASE

In connection with my application for employment with you, I understand that an investigative consumer report is being requested from DAC Services...

I understand that my employment can be terminated, with or without cause, at any time at the discretion of either the company or myself.

Applicant's Name:
Date:
Email:

To submit this form, please enter the characters you see in the image:

Image verification