Last name: First name: Middle initial:

Address:

Street: City: State:

Zip:

Home phone: Cell phone:

Email: Date of birth: (mm/dd/yyyy)

Nearest relative not living with you:(in case of emergency)

Name: Phone number:

Address for last 3 years:

Street: City: State:

Zip: How long:

Type of valid driver's licence tou now hold:

A B C D

Licence number: # of points

State held: Endorsements:

Have you been licensed in any other state(s) within the past 3 years?
Yes No
If so, which states?

Past 5 years Driving Record must be provided before applicant can be accepted.

(can be obtained from DMV)

Driving experience: Tractor-trailer Straight truck Other

Accident record for past 3 years:

Last accident: Nature: Fatalities/injuries:

Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes No

Have any licenses, permits or privileges ever been suspended or revoked?
Yes No
(if YES to above A or B, attach statement giving details)

Have you registered for the selective services?

The Draft

Military Service(U.S.)

Branch of Service: Date entered: (mm/dd/yyyy)

Date discharged: (mm/dd/yyyy) Miltary Job:

Highest Rank: Was discharge honorable? Yes No

Educational Background:

School :: Location :: Dates attended :: Graduated

Middle:

High:

College:

GED:

Additional Training:

Previous Employment Experience

Please give 10 years of job history, if applicable; include times of unemployment and additional schooling.

Begin with your most recent job and work backwards.

Date of employment: From (mm/dd/yyyy) To

Employer: Telephone:

Address:

Supervisor's name: Job Title:

Why did you leave?

Date of empoyment: From: (mm/dd/yyyy) To:

Employer: Telephone:

Address:

Supervisor's name: Job title:

Why did you leave?

Date of empoyment: From: (mm/dd/yyyy) To:

Employer: Telephone:

Address:

Supervisor's name: Job title:

Why did you leave?

Date of empoyment: From: (mm/dd/yyyy) To:

Employer: Telephone:

Address:

Supervisor's name: Job title:

Why did you leave?

Date of empoyment: From: (mm/dd/yyyy) To:

Employer: Telephone:

Address:

Supervisor's name: Job title:

Why did you leave?

Have you ever been convicted of a felony?

Yes No

If yes, please explain.

Have you ever been convicted of a drug offence of any kind, including probation before judgement?

Yes No

Please explain:

If yes, please answer the following questions.

Are you on probation? Yes No

Number of convictions? Date of convictions: (mm/dd/yyyy)

Are you A Diabetic? Yes No

Do you have High Blood Pressure? Yes No

Please briefly explain why you want to be a truck driver?

Check all that apply:

I am interested in driving: Local Regional Over the road Any

          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. I do not agree.

Where did you learn about this program?

News Journal The Guide Daily News Billboard DOL Truck

Referral by: Other:

I give American Driver Training my permission to pull my credit report.
I permit I do not permit

Name: Date: (mm/dd/yyyy)