Mid-State Application

Student Name*

First NameLast Name

Course Title	Price	Class Length
Class A	$3997- $4997 (Deposit $1,997) FINACING AVAILABLE	6-8 Weeks
Class B	$2497- $3497 (Deposit $1,997) FINACING AVAILABLE	6-8 Weeks
Class A Refresher Course	$1,297- $2497 (Must have class A CDL)	1-3 Weeks Part-Time
CDL Permit Course	$97	1 Day-Online (self-paced)
CDL Class A Hazmat Course	$147	1 Day- Online (self-paced
Trucking Mentorship- Entrepreneur Track	$997	1 Year- Online, Phone and In Person Events

Age*

Gender*

MaleFemaleNon Binary

Date of Birth*

Date

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you already have a CDL Permit?*

YESEnroll Me in the Online Permit Course for $97

Which course are you interested in? *

Potential Start Date?*

CDL Course last 6 to 8 weeks. Classes are 5 days a week Tuesday-Thursday (Monday & Friday can be reserved for extra practice by appointment), OR 2 days a week on Saturday & Sunday. Which option works for you?*

9am-Noon1pm-4pm6pm-9pmSaturday & Sunday 9am-4pm

Drivers License Number*

Drivers License State*

Emergency Phone Number*

Please enter a valid phone number.

Preferred time for call back*

Hour Minutes

AM/PM Option

How Will You Be Paying*

If you select financing please include your SSN and employer.

SSN

Employer

INTERVIEW. The school admin will conduct an interview with the student as part of the screening test. REQUIREMENTS. It is important to pass and complete all requirements before school starts. Failure to do so may delay the student from coming to school. MEDICAL CLEARANCE. For new students, medical clearance from a doctor is required. BEHAVIOR. Good moral is required while attending this school.

If you need financing the following paragraph applies to you.

By checking this box, I hereby consent to the "E-Sign Agreement", the "Credit Authorization Agreement", the "Terms of Service", and "Privacy Policy", and am providing written consent under the FCRA for Flexxbuy LLC. and its partners and their affiliated companies via email and/or at the telephone numbers(s) I have provided above to explore personal loan offers, including contact through automatic dialing systems, artificial or pre-recorded voice messaging, or text message. Consent is not required as a condition to utilize Flexxbuy LLC, and you may choose to be contacted by an individual customer care representative(s) by calling (866) 343-5268

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Signature*

Date Signed*

Date

Application Form