ÿþ<html> <head> <title>American Driver Training Academy - Application Form</title> </head> <body topmargin="0" bgcolor="#182E53"> <script language=JavaScript src="copyright.js"></script> <table width="100%" height = "98%" border="0" cellpadding="0" cellspacing="0" bordercolor="#EEEEEE"> <tr><td align="center" valign="center" colspan="2"> <table width="760" border="0" cellpadding="0" cellspacing="0" bordercolor="#EEEEEE" > <tr><td width="760"> <table width="760" border="0" cellpadding="0" cellspacing="0" bordercolor="#000000" > <tr> <td width="760" colspan="3"> <img src="americanbanner.jpg" width="760" height="105" align="center"> </td> </tr> <tr><td background= "bar.jpg" height="35" width="90" align="center"> <img src="brasao.gif"></td> <td background= "bar.jpg" align="center"> <object classid="clsid:d27cdb6e-ae6d-11cf-96b8-444553540000" codebase="http://fpdownload.macromedia.com/pub/shockwave/cabs/flash/swflash.cab#version=8,0,0,0" width="600" height="32" id="menu" align="middle"> <param name="quality" value="high"> <param name="menu" value="false"> <param name="allowScriptAccess" value="sameDomain" /> <param name="movie" value="menu.swf" /><param name="quality" value="high" /><param name="bgcolor" value="#ffffff" /><embed src="menu.swf" quality="high" bgcolor="#ffffff" width="600" height="32" name="menu" align="middle" allowScriptAccess="sameDomain" type="application/x-shockwave-flash" pluginspage="http://www.macromedia.com/go/getflashplayer" /> </object> </td> <td background= "bar.jpg" height="35" width="90" align="center"> <a href="application.html"> <img src="english.jpg" alt="English" border="0"></a> <a href="application_sp.html" > <img src="spanish.jpg" alt="Español" border="0"></a> <a href="application_pt.html"> <img src="portuguese.jpg" alt="Português" border="0"></a></td> </tr> <tr> <td height="350" align="center" background="stars.jpg" colspan="3"> <table border="0" width="100%" height="100%" cellpadding="2" cellspacing="2" bordercolor="blue"> <tr> <td><font face="verdana"> <p><strong><em>AMERICAN DRIVER TRAINING ACADEMY, INC.</em></strong><br><strong><em>19-B DAVIDSON LANE</em></strong><strong></strong><br /> <strong><em>NEW CASTLE, DE&nbsp; 19720</em></strong><br /> <strong><em>(302) 655-4511&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; FAX (302) 655-1746</em></strong></p> <strong>Please feel free to choose.</strong><br><p> To download the student application please <a href="studentapp.doc"><font color="red">click here</font></a> <br> <br> For the printable version of the student application please <a href="printstudapp.html" target="blank" ><font color="red">click here</font></a> <br> <br> Or you can fill out the online student application below and submit it.<p> <hr> <form id="form1" name="form1" method="post" action="aspmailform.asp"> <label> <input type="radio" name="I am " value="Mr." /> Mr</label> <label> <input type="radio" name="I am " value="Mrs." /> Mrs</label> <label> <input type="radio" name="I am " value="Ms." /> Ms</label> <p>Last name: <input type="text" name="Last name:" /> First name: <input type="text" name="First name:" /> Middle initial: <input type="text" size="6" name="Middle initial:" /> <p>Address:</p> <p>Street: <input type="text" name="Street:" /> City: <input type="text" name="City:" /> State: <input type="text" name="State:" /> </p> <p>Zip: <input type="text" name="Zip" /> </p> <p>Home phone: <input type="text" name="Home phone: " /> Cell phone: <input type="text" name="Cell phone: " /> </p> <p>Email: <input type="text" name="Email: " /> Date of birth: <input type="text" size="8" name="Date of birth: (mm/dd/yyyy) " />(mm/dd/yyyy) </p> <p>Nearest relative not living with you:(in case of emergency)</p> <p>Name: <input type="text" name="Name of relative: " /> Phone number: <input type="text" name="Phone number of relative: " /> </p> <p>Address for last 3 years:</p> <p>Street: <input type="text" name="Address for last 3 years: Street: " /> City: <input type="text" name="City: " /> State: <input type="text" name="State: " /> </p> <p>Zip: <input type="text" name="Zip: " /> How long: <input type="text" name="How long: " /> </p> <p>Type of valid driver's licence you now hold:</p> <p> <label> <input type="checkbox" name="Type of valid driver's licence you now hold (A):" value="A" /> A</label> <label> <input type="checkbox" name="Type of valid driver's licence you now hold (B):" value="B" /> B</label> <label> <input type="checkbox" name="Type of valid driver's licence you now hold (C):" value="C" /> C</label> <label> <input type="checkbox" name="Type of valid driver's licence you now hold (D):" value="D" /> D</label> </p> <p><br /> Licence number: <input type="text" name="Licence number: " /> # of points <input type="text" name="#of points " /> </p> <p>State held: <input type="text" name="State held " /> Endorsements: <input type="text" name="Endorsements: " /> </p> <p>Have you been licensed in any other state(s) within the past 3 years?<br> <label> <input type="radio" name="Have you been licensed in any other state(s) within the past 3 years?" value="Yes. I have been licensed in other state(s) within the past 3 years." /> Yes</label> <label> <input type="radio" name="Have you been licensed in any other state(s) within the past 3 years?" value="No. I don't have been licensed in any other state(s) within the past 3 years." /> No</label> <br /> If so, which states? <input type="text" name=" in State(s) of: " /> </p> <p><strong>Past 5 years Driving Record must be provided before applicant can be accepted.</strong></p> <p><strong>(can be obtained from DMV) </strong><br /> </p> <p>Driving experience: Tractor-trailer <label> <input type="checkbox" name="Tractor Driving experience: " value="Tractor-trailer experience" /> </label> Straight truck <label> <input type="checkbox" name="Truck Driving experience: " value="Straight truck experience" /> </label> Other <label> <input type="text" name="Other driving experience: " /> </label> </p> <p><u>Accident record for past 3 years: </u><p> Last accident: <label> <input type="text" name="Last accident: " size="8"/> </label> Nature: <label> <input type="text" size="15" name="Nature: " /> </label> Fatalities/injuries: <label> <input type="text" size="15" name="Fatalities/injuries: " /> </label> </p> <p>Have you ever been denied a license, permit or privilege to operate a motor vehicle? <br> <label> <input type="radio" name="Have you ever been denied a license, permit or privilege to operate a motor vehicle?" value="Yes" /> Yes</label> <label> <input type="radio" name="Have you ever been denied a license, permit or privilege to operate a motor vehicle?" value="No" /> No</label> <br /> </p> <p>Have any licenses, permits or privileges ever been suspended or revoked? <br> <label> <input type="radio" name="Have any licenses, permits or privileges ever been suspended or revoked?" value="Yes" /> Yes</label> <label> <input type="radio" name="Have any licenses, permits or privileges ever been suspended or revoked?" value="No" /> No</label> <br /> (if YES to above A or B, attach statement giving details) </p> <p>Have you ever had a DUI or DWI? <br> <label> <input type="radio" name="Have you ever had a DUI or DWI?" value="Yes" /> Yes</label> <label> <input type="radio" name="Have you ever had a DUI or DWI?" value="No" /> No</label> <br /> <p><strong><u>Have you registered for the selective services?</u></strong></p> <p>The Draft <label> <input type="checkbox" name="Have you registered for the selective services?" value="I have registered for The Draft" /> </label> </p> <p><strong>Military Service(U.S.) </strong></p> <p>Branch of Service: <label> <input type="text" name="Branch of Military Service: " /> </label> Date entered: <label> <input type="text" name="Date entered: (mm/dd/yyyy)" />(mm/dd/yyyy) </label> </p> <p>Date discharged: <label> <input type="text" name="Date discharged: (mm/dd/yyyy)" />(mm/dd/yyyy) </label> Miltary Job: <label> <input type="text" name="Military Job: " /> </label> </p> <p>Highest Rank: <label> <input type="text" name="Highest Rank: " /> </label> Was discharge honorable? <label> <input type="radio" name="Was discharge honorable?" value="Yes. I was discharge honorable." /> Yes</label> <label> <input type="radio" name="Was discharge honorable?" value="No. I was not discharge honorable." /> No</label> </p> <p><strong>Educational Background:</strong><br /> </p> <p align="center">School :: Location :: Dates attended :: Graduated</p> <p>Middle: <label> <input type="text" size="97" name="Middle School: " /> </label> </p> <p>High: <label> <input type="text" size="99" name="High School: " /> </label> </p> <p>College: <label> <input type="text" size="95" name="College" /> </label> </p> <p>GED: <label> <input type="text" size="100" name="GED: " /> </label> </p> <p>Additional Training: <label> <input type="text" size="80" name="Additional Training: " /> </label> </p> <p><strong>Previous Employment Experience</strong></p> <p>Please give 10 years of job history, if applicable; include times of unemployment and additional schooling.</p> <p><u><strong>Begin with your most recent job and work backwards.</strong></u></p> <p>Date of employment: From <label> <input type="text" name="Date of employment: (mm/dd/yyyy) From " />(mm/dd/yyyy) </label> To <label> <input type="text" name="To " /> </label> </p> <p>Employer: <label> <input type="text" name="Employer: " /> </label> Telephone: <label> <input type="text" name="Telephone: " /> </label> </p> <p>Address: <label> <input type="text" name="Address: " size="95" /> </label> </p> <p>Supervisor's name: <label> <input type="text" name="Supervisor's name: " /> </label> Job Title: <label> <input type="text" name="Job Title: " /> </label> </p> <p>Why did you leave? <label> <input type="text" name="Why did you leave? " size="80"/> </label> </p><br><hr width="90%"> <p> <p>Date of employment: From: <input type="text" name="Date of Employment (2): (mm/dd/yyyy) From: " />(mm/dd/yyyy) To: <input type="text" name="(2) To" /> </p> <p>Employer: <input type="text" name="Employer (2): " /> Telephone: <input type="text" name="Telephone (2):" /> </p> <p>Address: <input type="text" name="Address (2): " size="95"/> </p> <p>Supervisor's name: <input type="text" name="Supervisor's name (2): " /> Job title: <input type="text" name="Job title (2): " /> </p> <p>Why did you leave? <label> <input type="text" name="Why did you leave? (2)" size="80"/> </label> </p><br><hr width="90%"> <p> <p>Date of employment: From: <input type="text" name="Date of Employment (3): (mm/dd/yyyy) From: " />(mm/dd/yyyy) To: <input type="text" name="(3) To" /> </p> <p>Employer: <input type="text" name="Employer (3): " /> Telephone: <input type="text" name="Telephone (3):" /> </p> <p>Address: <input type="text" name="Address (3): " size="95"/> </p> <p>Supervisor's name: <input type="text" name="Supervisor's name (3): " /> Job title: <input type="text" name="Job title (3): " /> </p> <p>Why did you leave? <label> <input type="text" name="Why did you leave? (3)" size="80"/> </label> </p><br><hr width="90%"> <p> <p>Date of employment: From: <input type="text" name="Date of Employment (4): (mm/dd/yyyy) From: " />(mm/dd/yyyy) To: <input type="text" name="(4) To" /> </p> <p>Employer: <input type="text" name="Employer (4): " /> Telephone: <input type="text" name="Telephone (4):" /> </p> <p>Address: <input type="text" name="Address (4): " size="95"/> </p> <p>Supervisor's name: <input type="text" name="Supervisor's name (4): " /> Job title: <input type="text" name="Job title (4): " /> </p> <p>Why did you leave? <label> <input type="text" name="Why did you leave? (4)" size="80"/> </label> </p><br><hr width="90%"> <p> <p>Date of employment: From: <input type="text" name="Date of Employment (5): (mm/dd/yyyy) From: " />(mm/dd/yyyy) To: <input type="text" name="(5) To" /> </p> <p>Employer: <input type="text" name="Employer (5): " /> Telephone: <input type="text" name="Telephone (5):" /> </p> <p>Address: <input type="text" name="Address (5): " size="95"/> </p> <p>Supervisor's name: <input type="text" name="Supervisor's name (5): " /> Job title: <input type="text" name="Job title (5): " /> </p> <p>Why did you leave? <label> <input type="text" name="Why did you leave? (5)" size="80"/> </label> </p><br><hr width="90%"> <p> <p>Have you ever been convicted of a felony? <p> <label> <input type="radio" name="Have you ever been convicted of a felony? " value="Yes, i have been convicted of a felony." /> Yes</label> <label> <input type="radio" name="Have you ever been convicted of a felony? " value="No, i have not been convicted of a felony." /> No</label><p> If yes, please explain.</p> <p> <textarea name="Felony Explanation" cols="85" rows="7" id="Explanation:" ></textarea> </p> <p>Have you ever been convicted of a drug offence of any kind, including probation before judgement?</p> <p> <label> <input type="radio" name="Have you ever been convicted of a drug offence of any kind, including probation before judgement?" value="Yes, i have been convicted of a drug offence of any kind, including probation before judgement" /> Yes</label> <label> <input type="radio" name="Have you ever been convicted of a drug offence of any kind, including probation before judgement?" value="No, i haven't been convicted of a drug offence of any kind, including probation before judgement" /> No</label> </p> <p>Please explain: <textarea name="Drug Offence Explanation" cols="85" rows="3" id="Explanation:"></textarea> </p> <p>If yes, please answer the following questions.</p> <p>Are you on probation? <label> <input type="radio" name="Are you on probation?" value="Yes, i am on probation." /> Yes</label> <label> <input type="radio" name="Are you on probation?" value="No, i'm not on probation." /> No</label> <br /> <br /> Number of convictions? <input type="text" name="Number of convictions: " size="5"/> Date of convictions: <input type="text" name="Date of convictions: (mm/dd/yyyy)" />(mm/dd/yyyy) </p> <p>Are you A Diabetic? <label> <input type="radio" name="Are you A Diabetic?" value="Yes, i am a diabetic." /> Yes</label> <label> <input type="radio" name="Are you A Diabetic?" value="No, i am not a diabetic." /> No</label> </p> <p>Do you have High Blood Pressure? <label> <input type="radio" name="Do you have High Blood Pressure?" value="Yes, i have high blood pressure." /> Yes</label> <label> <input type="radio" name="Do you have High Blood Pressure?" value="No, i haven't high blood pressure." /> No</label> </p> <p>Please briefly explain why you want to be a truck driver?</p> <p> <textarea name="Please briefly explain why you want to be a truck driver:" cols="85" rows="3" id="Why do you want to be a truck driver?"></textarea> </p> <p>Check all that apply:</p> <p>I am interested in driving: <input type="checkbox" name="I am interested in driving local" value="I am interested in driving Local." /> Local <input type="checkbox" name="I am interested in driving regional" value="I am interested in driving Regional." /> Regional <input type="checkbox" name="I am interested in driving over the road" value="I am interested in driving Over the road." /> Over the road <input type="checkbox" name="I am interested in driving any" value="I am interested in driving Any." /> Any</p> <p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; This certifies that I have completed this application and that all entries on it and information in it are true and complete to the best of my knowledge. I am aware that job placement is not a guarantee but American Driver Training Academy, Inc. will assist in any way possible upon completion of my training. <br> <label> <input type="radio" name="Agreement: " value="I agree. This certifies that I have completed this application and that all entries on it and information in it are true and complete to the best of my knowledge. I am aware that job placement is not a guarantee but American Driver Training Academy, Inc. will assist in any way possible upon completion of my training." /> I agree.</label> <label> <input type="radio" name="Agreement: " value="I do not agree. " /> I do not agree.</label> <br /> </p> <p>Where did you learn about this program?</p> <p> <input type="checkbox" name="Where did you learn about this program? " value="News Journal" /> News Journal <input type="checkbox" name="Where did you learn about this program? " value="The Guide" /> The Guide <input type="checkbox" name="Where did you learn about this program? " value="Daily News" /> Daily News <input type="checkbox" name="Where did you learn about this program? " value="Billboard" /> Billboard <input type="checkbox" name="Where did you learn about this program? " value="DOL" /> DOL <input type="checkbox" name="Where did you learn about this program? " value="Truck" /> Truck</p> <p>Referral by: <input type="text" name="Referral by: " /> Other: <input type="text" name="Other: " /> </p> </p> <p>Name: <input type="text" name="Name: " /> Date: <input type="text" name="Date: (mm/dd/yyyy)" />(mm/dd/yyyy) </p> <p><br /> </p> <INPUT TYPE="submit" VALUE="Submit"> <INPUT TYPE="reset" VALUE="Reset"> </p> <p>&nbsp </p> </form> </font> </td> </tr> </table> </td> </tr> </table> </td></tr> <tr> <td height = "20" bgcolor="#FFFDFD"> <p align="center"><font face="Verdana" size="1" color="#FFFFFF"> <a href="index.html" target="_self"> Home </a><font color="#666666">::</font> <a href="requirements.html" target="_self"> Requirements </a><font color="#666666">::</font> <a href="application.html" target="_self"> Student Application </a><font color="#666666">::</font> <a href="contact.html" target="_self"> Contact Us </a><font color="#666666">::</font> <a href="opportunities.html" target="_self"> Employment Opportunities</a> </tr> <tr><td height = "1" bgcolor="#DDDDFC"></td></tr> <tr><td height = "1" bgcolor="#9999BC"></td></tr> <tr> <td bgcolor="#F5F5FF"> <table width="100%" cellpadding="0" cellspacing="0" border = "0" align = "center"> <tr> <td width="1%"> </td> <td width="87%"><font size="1" color="#666666">Copyright 2007 - American Driver Training Academy - All rights reserved</font> <td></td> </td> <td width="29%" height = "20"> <a href="http://www.deltadesign.com.br" target="_blank"> <img src="delta.gif" alt="www.deltadesign.com.br" border="0"></td> </a> </tr> <tr><td height = "1" bgcolor="#DDDDFC"></td> </tr> </table> </td></tr> </table> </td></tr></table> </body> </html>