Admission Application - Central Penn CDL Academy

Date(Required)

MM slash DD slash YYYY

Social Security No.(Required)

Age(Required)

Birthdate(Required)

MM slash DD slash YYYY

Sex(Required)

Male

Female

Email(Required)

Race(Required)

For Department of Labor tracking only – please use the following codes: 1) Asian/Pacific Islander 2) American Indian/Alaskan Native 3) Black, Non-Hispanic 4) Hispanic 5) All other American minorities 6) White, Non-Hispanic 7) Non-Resident Alien 8) Prefer not to say

Full Legal Name(Required)

Phone Number 1(Required)

Phone Number 2(Required)

Current Street Address(Required)

Street Address City State ZIP Code

Years at Current Address(Required)

Previous Address(Required)

(if current address is less than 3 years)

Street Address City State ZIP Code

How long?(Required)

How did you hear about Central Penn CDL Academy?

Please write a specific name next to the item checked.

Former Student

Trucking Company

Newspaper

TV Sation

Program

Internet

Other

Former Student

Trucking Company

Newspaper

TV Sation

Program

Internet

Other

How does your family feel about your decision to learn about the trucking industry?

(check all that apply)

Interested

Cooperative

Enthusiastic

Not Interested

Why are you interested in becoming a professional truck driver?

How long have you been seriously considering becoming a truck driver?

What types of driving jobs would you be willing to accept?

(check all that apply)

Local

Regional

Over the road (long haul)

Could you accept employment within 2 weeks after completing training?(Required)

Yes

HEALTH

Date of last physical exam(Required)

MM slash DD slash YYYY

Results(Required)

Physical defects?(Required)

Yes

Describe(Required)

Have you ever had back trouble?(Required)

Yes

Do you have good hearing in both ears?(Required)

Yes

Do you have at least 20/20 vision (or correctable to 20/40) in both eyes?(Required)

Yes

Do you suffer from diabetes?(Required)

Yes

Do you suffer from high blood pressure?(Required)

Yes

Are you currently taking any medications (prescribed or over the counter)?(Required)

Yes

If yes, list:(Required)

Do you have any concerns about passing a drug screen?(Required)

Yes

Do you know of anything that might prevent you from passing a physical?

DRIVING RECORD

What class driver’s license do you hold?(Required)

License # and State(Required)

Have you ever held a driver’s license in another state?(Required)

Yes

What state(s)(Required)

Has your license ever been suspended, canceled, or denied in any state?(Required)

Yes

Why(Required)

Have you ever been convicted of driving with a suspended or revoked license?(Required)

Yes

If yes, explain(Required)

Have you ever been convicted of reckless or careless driving?(Required)

Yes

If yes, explain(Required)

Any moving violations, speeding tickets, or accidents (regardless of fault) in the last 5 years?(Required)

Yes

If yes, explain(Required)

Do you currently have any outstanding tickets in any state that you are aware of?(Required)

Yes

If yes, explain(Required)

Do you have any pending charges?(Required)

Yes

Explain(Required)

Number of accidents/incidents in the last five (5) years(Required)

Number of convictions (tickets) in the last five (5) years(Required)

If any, explain:

(Answering Yes to the * questions does not automatically disqualify you for admission.)

DOMESTIC SITUATION

Status

Single

Married

Divorced

Separated

Widowed

Spouse’s name

Age

# of Children

WORK HISTORY

Cover all positions for the last 5 years starting with the most recent. (Employers will not be contacted)

Present Employer

Address

How long employed?

Why are you dissatisfied with your current job?

Number of different employers you have worked for in the past three (3) years?

Were you terminated from any jobs in the past three years?(Required)

Yes

If yes, explain

Have you ever been told that you tested positive for drugs or alcohol?(Required)

Yes

If yes, explain

Past employers(Required)

Employer name

How long?

Reason for leaving?

EDUCATION AND MILITARY EXPERIENCE

Are you a high school graduate?

Yes

Highest grade completed

Have you ever attended another college, business, trade or technical school?

Did you serve in the military?

Yes

If yes, what branch

Rank at discharge

Served from

Were you discharged for any reason other than honorable discharge?

Yes

CRIMINAL RECORD

Do you have any charges currently pending?

Yes

Been convicted for possession, sale, or use of a narcotic or drug?

Yes

Failed a controlled substance test?

Yes

If you answered yes to any of these questions, explain

RELEASE OF INFORMATION
I authorize Central Penn CDL Academy to obtain a Motor Vehicle Report as part of my application process. If I am accepted for enrollment, I authorize Central Penn CDL Academy to forward information from this application and/or other school records to prospective employers. I hereby declare that all information I have provided is true in substance and in fact.

Signature(Required)

Class A CDL Program

Full-Time Program

Part-Time Program

Registration Fee Only

Funded by Employer or Government Agency

None

Class B CDL Program

Full-Time Program

Part-Time Program

Registration Fee Only

Funded by Employer or Government Agency

None

Class A CDL Hotshot Program

40-Hour Intensive Program

40-Hour Refresher Course

Registration Fee Only

Funded by Employer or Government Agency

None

Total

Payment(Required)

MasterCard

Visa

Supported Credit Cards: MasterCard, Visa

Card Number Expiration Date Security Code Cardholder Name

Application for Admission