PRE-ENROLLMENT QUESTIONAIRE

PLEASE ANSWER EACH QUESTION HONESTLY AND COMPLETELY. THE FOLLOWING QUESTIONS ARE SIMILAR TO THOSE FOUND ON EMPLYMENT APPLICATIONS, THIS ASSURES US OF YOUR EMPLOYABILITY POST-GRADUATION.

Date*

Date

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Type of work desired:*

LocalRegional11 Western States48 States OTR

In the last 3 years have you had any gaps of employment over 30 days?*

YESNO

Can you provide, if asked, a full 10 year work history?*

YESNO

Have you EVER been convicted of a Felony or Misdemeanor? If yes, please provide dates and details.*

Have you ever held a Commercial Drivers License or Permit? If yes, When? Is it still Valid? If yes, when does it expire?*

In the past 3 years have you been in any traffic accidents? If yes, were you at fault? Injuries? Fatalities?*

Have you ever been convicted of DUII? If yes, How many? Conviction date?*

Has your drivers license EVER been Suspended or Revoked? If yes, when and reason?*

In the past three years, have you had any moving violations including seat belt tickets? If yes, please provide conviction dates and details.*

All Commercial drivers must pass a Department of Transportation Physical Exam. Do you have and limitations which might keep you from passing this exam? Limitations might include high blood pressure not controlled by medication, high blood sugar, or other medical problems. If yes, please explain.*

Aisling Truck Academy complies with all drug and alcohol rules as stated in 49cfr parts 40 and 382 of the FMCSR. Initially you will perform a urine NON-DOT drug screen prior to class start as part of the enrollment process. You will then be required to perform a pre-employment DOT drug screen once you obtain your Commercial Learner's Permit. Each student in each individual class will be entered into a random drug and alcohol testing pool and one student from each class will be sent in for random drug and alcohol testing. A DOT positive drug or alcohol test, refusal to test, or submission of an adultered specimen will negatively impact employability and will result in termination of enrollment at Aisling Truck Academy. Violators of drug and alcohol testing are not employable, in most cases, for at least 5 years from the date of violation.

Have you ever tested positive/refused tests for drug/alcohol, and if so, when?*

How did you hear about Aisling Truck Academy?

Aisling Truck Academy prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any activity conducted or funded by Aisling Truck Academy.

I Certify that all answers provided on this questionnaire are true and factual. I understand that failure to answer these questions contained in this questionnaire could negatively impact my ability to find employment if I am approved for training with Aisling Truck Acaemy. I understand that this questionnaire's purpose is to be used as a screening device to assure employability as a Commercial Driver.

Additional questions or comments.