Today Date Name Address City Home Phone
Driver License No. Email Address State Zip code Cell Message

DRIVING RECORD
You will be required to provide your driving record printout to YUBA SUTTER TRUCK DRIVING SCHOOL INC Prior to school acceptance

ANY MOVING VIOLATIONS LAST 3 YEARS?
YesNo

How Many:

ANY ACCIDENTS THE LAST THREE YEARS?
YesNo

How Many:

ANY CARELESS OR RECKLESS PAST 7 YEARS?
YesNo
How Many:

ANY DRIVING UNDER THE INFLUENCE VIOLATIONS THE PAST 7 YEARS?
YesNo

ANY RESTRICTIONS ON YOU LICENSE?
YesNo

Describe:

HEALTH QUESTIONAIRE
As a commercial driver you will be required to pass a DOT physical exam. These items are what they check for:

ARE YOU COLOR BLIND?
YesNo

CORRECTABLE HEARING?
YesNo

DO YOU HAVE DIABETES?
YesNo

DO YOU HAVE HIGH BLOOD PRESSURE?
YesNo

CORRECTABLE VISION?
YesNo

DO YOU HAVE EPILEPSY?
YesNo

EVER HAVE FAINTING SPELLS?
YesNo

ON ANY MEDICATION?
YesNo

PLEASE EXPLAIN ANY YES ANSWERS

DEMOGRAPHICS

Gender
MaleFemale

ARE YOU A VETERAN?
YesNo

HAVE YOU EVER BEEN CONVICTED OF A FELONY?
YesNo

Age Branch of Service Heighest Education Completed

EMPLOYMENT HISTORY
Please fill out completely, begin with present or most recent employment first.

Dates
Employer City
Position
Salary
Reason for Leaving

HOW DID YOU HEAR ABOUT US?
Please check all that apply to you.

NEWSPAPERPHONE BOOKTVRADIOINTERNETVETERANSEDD OFFICEONE STOP OFFICEREHAB OFFICEA FRIENDOTHER

IF IT WAS A TRUCKING COMPANY, PLEASE TELL US WHICH ONE: IF IT WAS A FORMER STUDENT, PLEASE TELL US WHO:

IN CASE OF EMERGENCY

Notify Address Phone
Relationship City Work Number

Other Reference

Notify Address Phone
Relationship City Work Number

I understand that if accepted for training, I hereby authorize Sac Truck Driving School Inc. Placement Department to forward this information to prospective employers. I further acknowledge that I have read the entire application and that all answers, statements and all other therein are true in substance and in fact

Not a Refund

Signature
Date