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 First and Last Name  
 E-Mail Address          
Phone Number                   
 Mailing Address        
 City, State, Zip          
 
 Please Answer These Questions Yes No   Please Answer These Questions Yes No 
 1. Can you read, write and clearly speak  the English Language?

 

 19. Have you ever been treated for any type or mental illness?

 

 2. Have you ever driven a truck commercially?      20. Have you ever been arrested for DWI, DUI, or reckless driving?    
 3. Are you 21 years of age or older?

 

    21. Have you ever been convicted of a misdemeanor?

 

  
 4. Do you have a current Driver’s Medical Examination Card?      22. Are you presently under indictment or charged with any type of crime?    
 5.  Do you have a current, valid Driver’s License?      23.   Have you ever been convicted of a felony?    
 6.  Have you been licensed to dive a vehicle continuously for the past 5 years?      24. Have you ever used any type of illegal drugs (controlled substances)?    
 7. Are you married?       25. Do you have an application pending with any other training facility?    
 8. Have you ever served in the armed forces of the United State?      26. Have you ever had a student loan for educational purposes?    
 9. If #8 is yes, have you been Honorable Discharged?      27. Has drinking ever interfered with your work?    
 10. Are you willing to take a drug test prior to training?      28. Has your driver’s license ever been suspended, revoked or restricted?    
 11. Have you been continuously employed for the last 5 years?      29. Do you have any physical or mental medical disabilities at this time?    
 12.  Are you willing to relocate to obtain employment?      30. Have you had any vehicular accident(s) during the last 3 years?    
 13.  Are you currently on any prescription medication?  If yes, please lis at the bottom:      31. Have you received any vehicular traffic citations in the last 3 years ?    
 14. Have you physically lost any part of your body or have any physical restrictions?       32. Are you presently employed either full or part time?    
 15. Do you presently have to wear corrective lenses to drive a vehicle?      33.  Are you a citizen of the United States?    
 16.  Do you presently have to wear a hearing aid?      34. Are you registered for Selective Service? (The Draft)    
 17.  Have you ever been fired from any of your previous jobs?      35. Can you verify your employment or education history for the last 10 years?    
 18.  Have you ever been injured on the job and/or paid workmen’s compensation?    

 36. What date could you begin training?

 

Explain any answers you need to clarify from above:

Have you previously had or do you now have any of the following:
 

Yes

 No   Yes No
Head or spinal injuries

Nervous stomach  
Seizure, fits, convulsions, or fainting Rheumatic Fever  
Extensive confinement by illness or injury Asthma  
Cardiovascular disease Kidney Disease  
Tuberculosis   Muscular disease    
Syphilis Suffering from any other disease  
Gonorrhea   Permanent defect form illness, disease or injury    
Diabetes Psychiatric disorder  
Gastrointestinal Ulcer Any other nervous disorder  


 Read the Disclosure and Release
 DRIVER’S LICENSE INFORMATION:
 Name as it appears on current license:  
 Previous Name(s):      (If applicable)    

 Date Of Birth             Social Security #         

 License Number    State Issued: Expires:

IF THE ISSUE DATE ON THE ABOVE LICENSE IS LESS THAN 3 YEARS YOU MUST LIST THE LICENSES YOU HAD BEFORE THE ONE ABOVE. (IF YOU DO NOT KNOW THE # GIVE AT LEAST STATE AND APPROXIMATE YEARS)
 
Previous License #  State Issued: Expires:
IF THE ISSUE DATE ON THE ABOVE LICENSE IS LESS THAN 3 YEARS YOU MUST LIST THE LICENSES YOU HAD BEFORE THE ONE ABOVE. (IF YOU DO NOT KNOW THE # FIVE AT LEAST STATE AND APPROXIMATE YEARS)