Enrollment Form

When would you like to start?
 ASAP 2 Weeks 3+Weeks Keenesburg Day Class

Applicants are considered without regard to race, creed, color, sex, religion, age, national origin or disability.

Personal information

As a tractor trailer operator I am:
 Inexperienced Experienced Owner-Operator

Drivers License Record

Traffic convictions/forfeitures : Driving citations received for the past five (5) years, moving and non-moving

Accident report : List all vehicle accidents/incidents for the past five (5) years

 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No

Additional traffic violation history

 Y N
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
 Y N
Have you ever had any license, permit or privilege suspended or revoked?
 Y N
Have you ever been convicted or charged with a misdemeanor?
 Y N
Have you ever been convicted or charged with a felony?
 Y N
Have you ever been convicted or charged for driving under the influence of alcohol or drugs?
 Y N
Have you ever been convicted or charged for possession, sale or use of a narcotic drug, amphetamine or derivative?
 Y N
Have you ever been disqualified to drive by federal regulations?
 Y N
Have you ever been refused liability insurance?
 Y N
Have you ever been refused a security bond?

(If YES to any give brief details & dates)

Military service and/or Reserve duty status
 Y N
DD-214 Type of discharge
 Honorable Dishonorable General Other

Explanation for general or other discharge

Employment history: A minimum of the previous three (3) years

Current or most recent employer
Dates of employment:month/year
From To
2nd Most recent employer
Dates of employment:month/year
From To
3rd Most recent employer
Dates of employment:month/year
From To
4th Most recent employer
Dates of employment:month/year
From To
By submitting this application, I certify that all the information on this form is correct and complete to the best of my knowledge. I understand that the information in this application will be used and that prior employers will be contacted for purposes of investigation required by 391.23 of the Federal Motor Carrier Safety regulations. I hereby authorize the release of any information on this application and I release said persons, previous employers and Careers World Wide, Inc. from any liability or damages.
I agree to terms above?
 Y N