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Driving School Application

Personal Information:
Full Name:
SSN:
Date of Birth:
Age:

Present Address And Contact Information:
Address:
City:
State:
Zip:
How Long:
Home Phone:
Cell Phone:
Email:

Admission Information:
All questions below are required.

Do you have a high school diploma or GED?
Yes    No

List ALL Driver's Licenses (held in the past 5 years)

1. State: Lic.#: Type: Expiration: Penalty:

2. State: Lic.#: Type: Expiration: Penalty:

3. State: Lic.#: Type: Expiration: Penalty:

4. State: Lic.#: Type: Expiration: Penalty:

 

 
Have you ever had any traffic convictions and forfeitures?
Yes    No

If you answered "Yes" to the above, list dat, vehicle, location, charge and penalty?

A. Has any license, permit or privilege ever been revoked?
Yes    No

 

B. Have you ever been arrested/convicted for driving under the influence of drugs or alcohol or do you have any current charges pending?
Yes    No

 

C. Have you ever been arrested/convicted for possession, sle, or use of a narcotic drug, amphetimine, or derivative or have a current charge pending (including marijuana)?
Yes    No

 

D. Have you ever been convicted of a crime or have a current charge pending?
Yes    No

 

E. Have you ever been convicted of an offense involving the use of drugs or alcohol?
Yes    No

 

F. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer?
Yes    No

 

If you answered "Yes" to either, A,B,C,D,E or F, you must state the circumstances and date:
Have you had any traffic/vehicle accidents in the last 5 years?
Yes    No

If you answered "Yes" to the above, list the date, vehicle, accident, were you at fault, ticketed, fatal,
injury and amount of damages?
Have you ever had your license suspended?
Yes    No

If you answered "Yes" to the above, when?
Have you ever been convicted of a DWI/DUI?
Yes    No

If you answered "Yes" to the above, when?
Have you ever had a felony conviction?
Yes    No

If you answered "Yes" to the above, for what and when?


I have read the above terms and conditions and will adhere to them.