This Application Is a Legal Document; It Must Be Printed in Ink in Your Own Handwriting

OK C.D.L. TRAINING, LLC

Application for Enrollment

Today’s Date______

Start Date______

This application is a legal document; it must be printed in ink in your own handwriting.

ANY INFORMATION FOUND TO BE FALSE OR INTENTIONALLY OMITTED WILL BE CONSIDERED FALSIFICIATION OF THE APPLICATION AND WILL BE GROUNDS FOR IMMEDIATE TERMINATION.

Personal Information

Name ______

Last First Middle

Address______

City______State______Zip______

Home Phone ( ) ______Work Phone ( ) ______

Message Phone ( ) ______

Date of Birth______Social Security Number______

EMERGENCY CONTACTS

Name ______Phone ( ) ______

Address______

Relationship______

Name ______Phone ( ) ______

Address______

Relationship______

EDUCATION

Circle Highest Grade Completed: 1 2 3 4 5 6 7 8 High School: 9 10 11 12

College: 1 2 3 4

High School Graduate? Yes No Graduation or GED Completion Date ______

Last School Attended______

Address______

Degrees/Certificates______

MILITARY STATUS

Branch of Service______From______to ______

Rank at Discharge______Date of Discharge______

MOTOR VEHICLE LICENSES HELD

License______State______

ACCIDENT RECORD

List ALL accidents with any motor vehicle for the past 10 years. If non, write “None”.

Date______State______

Nature of Accident______At Fault? ______

Date______State______

Nature of Accident______At Fault? ______

Date______State______

Nature of Accident______At Fault? ______

TRAFFIC CONVICTIONS

List ANY and ALL traffic convictions and forfeitures for the past 10 years. If none, write “None”.

Date______State______Violation______Penalty______

DOT FEDERAL REGULATIONS REQUIRE THAT ALL TIME BE ACCOUNTED FOR DURING THE LAST 10 YEARS

10 YEAR EMPLOYMENT HISTORY

Begin with your present employer or current status and work backward in order. You must list ALL of your employers, ALL periods of employment, ALL periods of military service, ALL self employment for the last TEN years. THERE CAN BE NO GAPS!!

May we contact your present employer ( if any) to verify your work record?

Yes______No______

Company______

Position Held ______

Address______

Phone( )______Supervisor______

From______to ______

Reason for Leaving______

Company______

Position Held ______

Address______

Phone( )______Supervisor______

From______to ______

Reason for Leaving______

Company______

Position Held ______

Address______

Phone( )______Supervisor______

From______to ______

Reason for Leaving______

Company______

Position Held ______

Address______

Phone( )______Supervisor______

From______to ______

Reason for Leaving______

RACE/ETHNICITY

White/ Caucasian Hawaiian Native or other Pacific Islander

Black/African American Multi Racial

Hispanic Other

Am. Indian/Alaska Native Unknown

Asian

CRIMINAL CONVICTIONS

List ALL misdemeanor and felony convictions. If non, write “None”.

Date______State______County______Felony/Misdemeanor______

Charge ______Sentence/Penalty______

Date______State______County______Felony/Misdemeanor______

Charge ______Sentence/Penalty______

Date______State______County______Felony/Misdemeanor______

Charge ______Sentence/Penalty______

Date______State______County______Felony/Misdemeanor______

Charge ______Sentence/Penalty______

OK C.D.L. TRAINING

P.O. Box 621

Tonasket, WA 98855

The following need to be sent with your application to OK C.D.L. Training

1. C.D.L. Complete driving abstract.

2. DOT drug test. Taken at Omak Clinic. This has to have our school name on it and mailed to us.

3. C.D.L. Physical

If you have any questions feel free to give us a call

Bonnie Andrews (509) 486-4954

Cheril Sweany (509) 322-8884