Iowa Central Truck Driving Admissions Application

* indicates a required field

Personal Information
Enter your name as it appears on your Social Security Card
*
First Name (legal name):
A value is required.
 
Nickname:
 
Middle Name/Initial:
*
Last Name (surname):
A value is required.
 
Maiden Name:
 
SSN:
*
Birth Date (MM/DD/YYYY):
A value is required.Invalid format. Must be in MM/DD/YYYY format.
*
Sex:
Please select an item.
*
Address:
A value is required.
 
P.O. Box:
*
City:
A value is required.
 
County:
*
State:
A value is required.
*
Zip Code:
A value is required.
 
Home Phone:
Invalid format. Must be in (123) 456-7890 format.
 
Cell Phone:
Invalid format. Must be in (123) 456-7890 format.
*
E-Mail:
(enter only 1 e-mail address)
A value is required.Invalid format.
 
Iowa Resident:
 
Date of Residency:
 
Are you a US Citizen:
If you answered no:
  * Country of Birth: A value is required.
  * Country of Citizenship: A value is required.
  Type of Visa: A value is required.
 
Have you served in the U.S. Armed Forces?
  * Branch: Please select an item.
  * List Dates Active: Please enter the dates you were active.
 
Is English your native language?

Emergency Contact Information
 
Contact:
 
Other:
*
Name:
A value is required.
*
Phone:
A value is required.Invalid format. Must be in (123) 456-7890 format.

High School Information
*
Name of High School Last Attended:
A value is required.
*
Graduation Year:
A value is required.
*
City:
A value is required.
*
State:
A value is required.
 
If not a high school graduate, have you earned the GED:
 
Date GED Earned:
 
Highest Level of College Completed:
 
Highest Level of Trade School Completed:

Physical History
 
List any physical limitation (such as eyesight, limb impairment, diabetes, etc.)
 
Are you physically capable of heavy manual work?
Please select an item.
 
Date of last physical examination:
 
Have you ever been injured on the job?
 
If you answered Yes above, give the nature of your injuries:
 
How much time lost from work in the past 3 years for illness:
 
Have you received workman's compensation?
 
If you answered Yes above, when?
 
Name of an individual (other than a relative) that can verify periods of unemployment:
 
Phone number of an individual (other than a relative) that can verify periods of unemployment:

Employment Record for the Past 3 Years

People with previous driving experience (CDL holders must include an additional 7 years of work experience

Employer Name:
Supervisor:
Address:
City:
State:
Zip Code:
Position Held:
Date Started:
Date Ended:
Phone:
Reasons for leaving

Employer Name:
Supervisor:
Address:
City:
State:
Zip Code:
Position Held:
Date Started:
Date Ended:
Phone:
Reasons for leaving

Employer Name:
Supervisor:
Address:
City:
State:
Zip Code:
Position Held:
Date Started:
Date Ended:
Phone:
Reasons for leaving
 

General Information
Have you ever been bonded:
Name of bonding company:
Have you ever been refused bond:
If yes to above, why?
Have you ever been known by any other name other than the one on this application:
If yes to above, list the name(s):

Driver Experience and Qualifications
Current Driver's License Type:
State the Issued License:
License Number or Audit Number:
License Expiration Date:

Driving Experience
Class of Equipment:
Type of Equipment:
Date From:
Total Number of Miles Driven:

1. Have you EVER been denied a license, permit, or privilege to operate a motor vehicle?
2. Have you EVER had any license, permit, or privilege been suspended or revoked?
3. Have you EVER been convicted for driving under the influence of alcohol or drugs?
4. Have you EVER been refused liability insurance?
5. Have you EVER been convicted of a felony?
6. Have you EVER been convicted of a misdemeanor?
7. Have you EVER been disqualified to drive by Federal Regulations?
8. Per Section 40.25 of the 49 CFR Part 40 Final Rule: Have you ever tested positive, or refused to take pre-employment alcohol/drug screening, whether the employer hired you or not, within the past 2 years?
9. Have you had any traffic convictions in the last 3 years?
10. Have you had any accidents in the last 3 years?
If you answered Yes to ANY of the above 10 questions, state the details, circumstances, and date below.

References
*
Name:
A value is required.
* Address: A value is required.
* City: A value is required.
* State: A value is required.
* Zip Code: A value is required.
* Phone: A value is required.Invalid format.
* Relationship: A value is required.

*
Name:
A value is required.
* Address: A value is required.
* City: A value is required.
* State: A value is required.
* Zip Code: A value is required.
* Phone: A value is required.Invalid format.
* Relationship: A value is required.

*
Name:
A value is required.
* Address: A value is required.
* City: A value is required.
* State: A value is required.
* Zip Code: A value is required.
* Phone: A value is required.Invalid format.
* Relationship: A value is required.

You must check the box to the left in order to submit the form. By checking this box it is agreed and understood that any misrepresentation of information given above shall be considered an act of dishonesty. It is agreed and understood that the school or its agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record. whether the same is of record or not, and the applicant release employers and persons named herein from all liability for any damages on account of furnishing such information. The applicant agrees to furnish such additional information and complete such examinations as may be required to complete his/her student file. It is agreed and understood that this application for acceptance in no way obligates the school to accept the applicant and that if accepted, the student will be on a probationary period during which time he/she may be dismissed without refund.

By checking the box above it certifies that I completed this application and that entries on it and information in it are true and complete to the best of my knowledge.

By checking the box above I understand that the information in this application will be used and that prior employers will be contacted for purposes of investigation as required by 391.23 of the motor Carrier Safety Regulations.

Non-Discrimination Statement
It is the policy of Iowa Central Community College not to discriminate on the basis of race, color, national origin, sex, disability, age (employment), sexual orientation, gender identity, creed, religion, and actual or potential parental, family or marital status in its programs, activities, or employment practices as required by the Iowa Code §§ 216.6 and 216.9, Titles VI and VII of the Civil Rights Act of 1964 (42 U.S.C. §§ 2000d and 2000e), the Equal Pay Act of 1973 (29 U.S.C. § 206, et seq.), Title IX (Educational Amendments, 20 U.S.C. §§ 1681 – 1688), Section 504 (Rehabilitation Act of 1973, 29 U.S.C. § 794),  Age Discrimination Act of 1975 (34 CFR Part 110), and Title II of the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.).

If you have questions or complaints related to compliance with this policy, please contact Kim Whitmore, Director of Human Resources, phone number 515-574-1138, whitmore@iowacentral.edu; or the Director of the Office for Civil Rights, U.S. Department of Education, Citigroup Center, 500 W. Madison, Suite 1475, Chicago, IL 60661, phone number 312-730-1560, fax 312-730-1576.

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