Student Interview

Date:
Name*:
Address*
Phone*:
Email Address*:
Birth Date*:

IT IS IMPORTANT THAT ALL QUESTIONS BE ANSWERED COMPLETELY

Driver's License Number:
SSN:

How will your schooling be paid for?
How did you hear about Check Ride?

Can you meet the following requirements in order to receive a CDL Learner's Permit?


DIRECTIONS: Please answer the following YES and NO questions. If "No," please move onto the next question. IF "Yes," please explain in the box below the question.

Is there anything on your driving record in the past five (5) years?


Have you ever been convicted of an alcohol or drug related traffic violation?
Is your license currently or has it ever been suspended or revoked in Washington or any other state?
Do you have any medical, physical or learning disability problems that could hinder your truck driver training?
Do you have any medical problems & are you on any prescribed medications?
Do you currently have any outstanding or unpaid traffic fines?
Have you ever been convicted of a felony or misdemeanor?
Have you ever failed a DOT or Random Drug Test?
Have you ever taken illegal drugs?

Work history for the last THREE years. THIS IS REQUIRED INFO BY THE DOT.

Name of Employer
Dates Employed
Supervisor
Phone # (area code)
Address
Job Responsibilities
Reason for Leaving
Eligible for rehire?

Name of Employer
Dates Employed
Supervisor
Phone # (area code)
Address
Job Responsibilities
Reason for Leaving
Eligible for rehire?

SUBMIT FORM NOW (REMAINDER TO BE COMPLETED UPON ENROLLMENT)

By signing, I testify that all information is true and accurate to the best of my knowledge. I also attest, that I have received ether verbally, or in writing, information on the trucking labor market, along with Check-Ride's latest job placement percentages.

SIGNATURE REQUIRED*
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