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585-742-2303
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Date of Birth *
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Which Class Are You Applying For? * AB
Do you have a job lined up? If so, with whom?
Martial Status * MarriedSingleDivorcedSeperated
Number of Dependants *
Emergency Contact Name*
Relationship *
Drivers License # *
Class * —Please choose an option—ABCDDJEMMJDon't Know
Expiration Date *
Have your served in the US Military? * YesNo
Highest Level of Education *
What Appeals to You About Trucking?
How Will You Be Paying for Course? *
If Accepted, When Can You Begin? *
Are You Interested In Long, Regional, or Local Haul? * LongRegionalLocalDon't Know
Are You a US Citizen? * YesNo
Resident Alien Date of Arrival
Character Reference #1 *
Character Reference #2 *
Current Employer *
Employed From *
To *
Position *
Previous Employer #1
Employed From
To
Position
Reason for leaving
Previous Employer #2
Previous Employer #3
Any moving violations in the last 5 years? * YesNo
Any accidents in the last 5 years? * YesNo
DWI/DUI/DWAI? * YesNo
Had a license suspended or revoked? * YesNo
Have any felony or misdemeanor convictions? * YesNo
Do you have at least 20/40 vision or better (with corrective lenses)? * YesNo
Do you have any hearing loss? * YesNo
Are you color blind? * YesNo
Do you have heart trouble? * YesNo
Do you have fainting or dizzy spells? * YesNo
Do you have epilepsy? * YesNo
Do you have diabetes? * YesNo
Do you take medication? * YesNo
Thank you for your interest in the Canandaigua Driving School! Please initial below to certify that the information you have provided is factual to the best of your knowledge. You also cetify that you are drug free. You authorize Canandaigua Driving School to perform a background check including a credit history if necessary and release Canandaigua Driving School and any persons providing information from all liability relating to the gathering or furnishing of information.
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