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Truck Driver Academy Enrollment Application

Name (As it appears on your Drivers License)


Home Address


Mailing Address (complete only if different than above)

Check this box if mailing address is different than your home address.

Contact Information

Personal Information


The following Information is for statistical use and may be used by state and federal agencies.

Male     Female

Native American Black     White     Asian     Hispanic     Pacific Islander     Other

Yes     No

Education

Junior High School         High School         College

In the absence of these documents, applicant will be eligible for training by passing the Ability to Benefit test.

Emergency Notification (if married spouse should be listed)


Medical Information


Yes     No



Yes     No



Yes No


Driving & Criminal History


Yes     No

Yes     No

Yes     No

Yes     No



Yes     No

Yes     No

By checking this box I acknowledge that I have truthfully answered the above questions.