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Have you ever had a DUI or DWI - American Driver Training Academy

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AMERICAN DRIVER TRAINING ACADEMY, INC.                             OFFICE USE ONLY
19-B DAVIDSON LANE                                                 CLASS _________________
NEW CASTLE, DE 19720
(302) 655-4511   FAX (302) 655-1746                                DAY     NIGHTS     WEEKENDS

                                                                   LOCAL   REGIONAL   OVER THE ROAD,
Circle one: Mr, Mrs, Ms,                                           ANY,

Name: _____________________________________________            Date_______
        (Last)               (First)          (M.I.)           Interviewed By_____________
                                                               ____________________________
Address: ___________________________________________           ____________________________
                                (Street)                       ____________________________
___________________________________________________ ____________________________
     (City)                      (State)          (Zip)        ____________________________
                                                               ____________________________
Home phone ______________Cell phone__________________ ____________________________
                                                               ____________________________
                                                               ____________________________
Email: ____________________________________
                                                               ____________________________
                                                               ____________________________
S.S #__________________ Date of birth __________________ ____________________________
                                                               ____________________________
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 license you now hold:                   ____________________________
A__B__D__ C__ License number __________# of points ____ ____________________________
                                                               ____________________________
State held ______Endorsements _________________________ ____________________________
Have you been licensed in any other states(s) within the past  ____________________________
3 years?______ If so, which state(s) ______________________ ____________________________
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)

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Have you ever had a DUI or DWI??
YES___ NO___

Have you registered for the selective services? (The Draft) ___________

Military Service (U.S.)
Branch of Service _____________ Date entered __________
Date discharged ____________________
Military 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 ______________________ To ___________________
Employer ______________________________________Telephone _____________
Address______________________________________________________________
Supervisor’s name _____________________________________________________
Job title ______________________________________________________________
Why did you leave?_____________________________________________________

Date of employment: From ______________________ To ____________________
Employer ______________________________________Telephone ______________
Address_______________________________________________________________
Supervisor’s name ______________________________________________________
Job title _______________________________________________________________
Why did you leave?______________________________________________________

 Date of employment: From ______________________To _____________________
 Employer _____________________________________Telephone _______________
Address_______________________________________________________________
Supervisor’s name ______________________________________________________
Job title ______________________________________________________________
Why did you leave?_____________________________________________________
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Have you ever been convicted of a felony? Yes ___ No___ If yes, please explain
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Have you ever been convicted of a drug offense of any kind, including probation before judgment?
Yes ___ No____ Please explain: _________________________________
______________________________________________________________________

If yes, please answer the following questions.
Are you on probation? Yes________________ No_________________________
Number of convictions? _________ Date of convictions:_____________________

     Are you A Diabetic ______. Do you have High Blood Pressure ______

Please briefly explain why you want to be a truck drive?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________


Circle 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.

Applicant’s Name_________________________________ Date _______________

Where did you learn about this program?
News Journal ___ The Guide ___ Daily News ___ Billboard ___ DOL ___ Truck ___
Referral ___ By___________________________ Other________________________




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