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 CenterClarion County Career CenterRegional Career and Tech Center - ErieLenape Adult EducationIndiana County Technology CenterNPRC - St MarysNPRC - Warren
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone 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:

MonthDayYear
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.