Excellence In Training
Student Enrollment Application
Personal Data
NAME
Last
First
M.I.
ADDRESS
City
Street
State
Zip
PHONE
Email
Mobile
Home
Drivers License #
DATE OF BIRTH
PRIMARY LANGUAGE
SuperSession
Standard Class A
Standard Class B-Truck
Class B Passenger
Class A/B Refresher
Class A/B Express
Class A/B Hourly
When would you like to start?
What programs are you applying for?
Driving History
Have you ever taken any of our courses before?
Yes
NO
If yes, please describe
Do you have a valid Class C license?
Yes
NO
Have you ever had a Commercial Driver License ( Class A or Class B)?
YES
NO
If yes, type of vehicle and how long ago?
Yes
NO
Do you have a current learners permit?
Any issues on your driving record that may be of concern?
Yes
No
If yes, please list (Time of occurrence(s) and nature of occurrence(s)
Please complete accurately and truthfully so that we can properly help you.
Criminal Background
-
Please complete accurately and truthfully so that we can properly help you.
Any criminal issues within the past 10 years?
(This does not exclude you from training but allows us to best assist with job placement.)
Yes
No
If yes, please list (Time of occurrence(s) and nature of occurrence(s)
Physical & Health Conditions
Please complete accurately and truthfully so that we can properly help you.
Are you taking any medication or have any medical or health issues?
Yes
No
If yes, please explain
( This does not automatically exclude you from training)
Referral Source
How did you hear about us
Friend
Yahoo
Google
EDD Office
Do you need financial assistance?
Yes
No
Are you a veteran?
Yes
No
Are you working with a funding agency ?
Yes
No
Contact Person
Phone
Name
Emergency Contacts
Phone
Name
Phone
Name
Training Location
Which location are you interested in attending?
Oakland
Stockton