Enrollment Form

    When would you like to start?
    ASAP2 Weeks3+WeeksKeenesburg 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:
    InexperiencedExperiencedOwner-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

    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo

    Additional traffic violation history

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

    (If YES to any give brief details & dates)

    Military service and/or Reserve duty status
    YN
    DD-214 Type of discharge
    HonorableDishonorableGeneralOther

    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?
    YN