Updated VTC Worksheet

Initial Qualifications Application
Please Note: This is not your enrollment documents. This form is just to give us a better understanding of each individual.
School *

Venango Technology Center Clarion County Career Center Regional Career and Tech Center - Erie Lenape Adult Education Indiana County Technology Center NPRC - St Marys Mercer County Career Center NPRC - Warren
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Any Moving Violations or Accidents in the past 5 years? *
If yes, Please list date and offense:
Careless, Reckless driving or Leaving the scene of an accident ever? *
If yes, what year and charge?
License Suspensions or DUI's ever? *
If yes, Please list date, offense and if suspension, the length of suspension:
Felonies Ever? *
If Yes, please list date(s) and charge(s):
Misdemeanors Ever? *
If yes, please list date(s) and charges(s):
Currently on probation or parole? *
If yes, till when:

Month Day Year
Date
Medical Issues: *
If yes, please list:
Any Seizures, current hernia's, Sleep Apnea or are you Insulin Diabetic? *
If yes, which conditions do you have?
Currently on any medication? *
If yes, please list:
Do you have a current DOT Physical? *
Currently Working? *
If No, are you laid off? *
Collecting Unemployment? *
Most Recent or Current Employer: *
How long were you or have been employed with them? *
Are you familiar with operating a vehicle with a manual transmission? *
Have you backed anything with a trailer attached to it? *
Please follow up with us at 814-670-0726 to discuss the application and the training. Office hours are Monday thru Friday 8:00 am to 4:30 pm.
Should be Empty:

Initial Qualifications Application

Please follow up with us at 814-670-0726 to discuss the application and the training. Office hours are Monday thru Friday 8:00 am to 4:30 pm.