Rocky Mountain Truck Driving School

The following questions will assist in identifying any possible area(s) that should be discussed regarding your future employment with a truck company.

Place an "X" for the correct answer to each question		YES	NO
1.	Is your employment/education history verifiable for the past five (5) years?
2.	Have you ever been fired from a job?
3.	Are you presently employed?
4.	Have you ever been injured on the job and/or paid workers compensation?
5.	Did you graduate from high school? If not, do you have a GED?
6.	Do you have a valid Driver's License? State _______________
7.	Are you over 21 years of age?
8.	Can you clearly understand, write and read the English language?
9.	Have you ever filed for bankruptcy?
10.	Have you ever had a student loan?
11.	Do you have any physical or mental medical disabilities at this time?
12.	Do you have any eye sight problems or color blindness? (Other than glasses?)
13.	Do you presently take any type of prescribed medication?
14.	Do you presently have to wear a hearing aid?
15.	Have you physically lost any part of your body?
16.	Have you ever been licensed to operate a commercial vehicle? Class ____
17.	Have you ever had a driver's license suspended or revoked for any reason?
18.	Have you ever been arrested or convicted of an alcohol/drug-related driving offense?
19.	Have you had any vehicular accidents during the last three (3) years?
20.	Have you received any vehicular traffic citations in the last three (3) years?
21.	Have you ever been arrested or convicted for possession, sale or use of a narcotic drug, amphetamine or other controlled substance?
22.	Have you ever been convicted of a crime (felony) or are any charges pending?

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I certify that all the information given above is correct and complete to the best of my knowledge. I agree that my enrollment is based on the facts that I have given and any intentional misrepresentation on my part will constitute a release to the school for any liability that it may encounter by having acted on such facts. I have read the above and understand it. I hereby authorize Rocky Mountain Truck Driving School to investigate and verify the facts claimed by me on this application.