Mid State Driving Application

Application Form

Financing Available To Those Who Qualify

Course Title	Price	Class Length
Class A	$4497 100% FREE WITH THE FOLLOWING PROGRAMS: WIOA GRANT- Career Center Youth Grant- DESI No Credit Check Financing Available (Deposit Required)	5-8 Weeks * Can finish faster based on individual skill level 16 Weeks Part-Time
UPGRADE CLASS B To CLASS A	$2497-$4497	6-8 Weeks * Can finish faster based on individual skill level
Class B	$2497-$3497	4-8 Weeks
CDL Refresher	$797-$1297	1-2 Weeks
Restriction Lift	$797-$1297	1-2 Weeks
CDL Class A Hazmat Course	$147	1 Day- Online (self-paced

Student Name*

First NameLast Name
Age*
Gender*

MaleFemaleNon Binary
Date of Birth*

MonthDayYear
Date
Last 6 Of Your SSN*
Email*
example@example.com
Phone Number*
Please enter a valid phone number. By providing your phone number you agree to receive SMS Test messages. Message & Data rates may apply. Reply Stop to unsubscribe or Help for help.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you already have a CDL Permit?*

YesNo
Which Location are you interested in?
Potential Start Date?*
Which course are you interested in? *
CDL Courses last 6 to 8 weeks. Classes are 3 days a week Tuesday-Thursday, OR 2 days a week on Saturday & Sunday. Which option works for you?*

9AM-12PM (Birmingham)9 AM- 12 PM (Montgomery)1PM-4PM (Montgomery)1PM-4PM (Birmingham)6PM-9PM (Montgomery)Saturday & Sunday 9AM-4PM (Montgomery)Saturday & Sunday 9AM-4PM (Birmingham)
Drivers License Number*
Drivers License State*
Emergency Phone Number*
Please enter a valid phone number.
How Will You Be Paying*
If you selected in house financing which package would you like?

Package B ($2000 Down, and $250 per month 10 months after CDL Certification)Package C ( $1300 Down, and $97 per week during training, $250 per month for 10 months after CDL Certification)Package D - PART TIME STUDENTS ONLY 16 Week Program ($500 Down, $97 per week during training, $250 per month for 10 months after CDL Certification)WIOA Grant *(Must apply at your local Career Center)DESI Grant (Must be under 24 years old)CASH NET USA & Referral Partner ( Must have a 530 FICO Credit Score)Other
Were you referred by anyone or company? If so please type their NAME AND NUMBER below:
Are you with an organization?

Career CenterSalvation ArmyDESI ( Must be under 24)Not with an organizationCompanyOther
Please select a day when we can give you a call to discuss your application*
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 MID STATE DRIVING ACADEMY 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 MID STATE DRIVING ACADEMY, and you may choose to be contacted by an individual customer care representative(s) by calling (866) 996-1889
Signature*

Clear
Date Signed*

MonthDayYear
Date
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Application Form