How old are you? Married Single Name of Spouse:
Do you have children? YES NO
Own home Rent How long have you lived here?
Military experience? YES NO How long? Date discharged Type:

Have you ever been convicted of a felony? YES NO

If yes, please explain fully:

Are you in good health? YES NO
Do you have at least a 20/40 vision in each eye with glasses YES NO
Do you have good use of : Hands Arms Feet Legs Good Hearing
Do you have any condition which could cause fainting spells? YES NO
Have you ever been treated for: Diabetes Epilepsy Heart Other
Use of Intoxicants: Habitual Occasional Seldom Not at All
Use of Drugs: Habitual Occasional Seldom Not at All
Any physical defects: YES NO

If yes, describe:

Date of last physical
I certify, to the best of my knowledge, I am in good condition: YES NO

Highest Grade Completed: 1 2 3 4 5 6 7 8 9 10 11 12 College 1 2 3 4 Diploma? YES NO GED? YES NO

Last school attended:

The U.S. Department of Transportation requires that driver applicants show all employment for the past three years. Effective July 1987, they must also show commercial driver employment for the seven years immediately preceding this three-year
period.

Start with last or current position, including military experience, and work background.

Current Employer: Supervisor's Name:

Address: Phone:

Position Held: From: To: Salary:

Reason for leaving:


Previous Employer: Supervisor's Name:

Address: Phone:

Position Held: From: To: Salary:

Reason for leaving:

Driver Licenses held in past 3 years must be shown.
State: License No. Type: Expiration Date:
State: License No. Type: Expiration Date:
State: License No. Type: Expiration Date:

Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES NO
Has any license, permit or privilege ever been suspended or revoked? YES NO
Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? YES NO

If you answered yes to any of the above, please state details:


Accident Review for past 3 years:

Last Accident - Nature of Accident: Fatalities Injuries

Previous Accident - Nature of Accident: Fatalities Injuries

Please list all Traffic Convictions and Forfeitures for the past 3 years other than parking violations:
include Location, Date, Charge, and Penalty for each violation



I UNDERSTAND THAT IN COMPLETING THIS APPLICATION THE SCHOOL IS UNDER NO OBLIGATION TO ACCEPT ME, NOR AM I UNDER OBLIGATION TO SHIPPERS CHOICE SCHOOLS. It is agreed and understood that the answers to the foregoing questions have been supplied by me and are true and correct to the best of my knowledge, and that any misrepresentation of information given above shall be considered and act of dishonesty.