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Mid-America Truck Driving School, Inc with campuses located in Malvern, & Springdale, Arkansas
Enrollment Application
Mid-America Truck Driving School, Inc
1609 N. Old Missouri Rd.
Springdale, AR 72764
(479) 756-1977 Phone
Mailing Address: P.O. Box 723 Malvern, AR 72104
(877) 844-4496 Phone (501) 844-4466 Fax
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Indicates required field
Choose One
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NWA- Springdale Campus
Jones Mill-Malvern Campus
select the campus nearest to where you reside.
Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
How Long At This Address
Drivers license number
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Issuing State, Date of issue, Classification, Expiration date.
Previous drivers license number
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Date
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Phone Number
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Date of Birth
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mm/dd/yyyy
SSN
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SSN: XXX-XX-XXXX
Email
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Most Recent Employer Name
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Start Date_____End Date_____
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From: mm/yy thru mm/yy
Phone Number
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Reason for Leaving
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2nd Most Recent Employer Name
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Address
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Line 1
Line 2
City
State
Zip Code
Country
3rd Most Recent Employer
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Start Date_______End Date______
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From: mm/yy thru mm/yy
Phone Number
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Reason for Leaving
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Start Date_______End Date______
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From: mm/yy thru mm/yy
Phone Number
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Reason for Leaving
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Accidents for past 3 years
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None
Yes
If yes, list them in the space provided below.
Date of Accident
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estimated month & year
Date of Accident
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Traffic violations
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None
yes
If yes, list those for moving violations only during the past 3 years.
Nature of Accident
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tailgating, changing lanes, failure to yield, speeding, road conditions,etc
Nature of Accident
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Damage Cost
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estimated cost of damage to your vehicle
Damage Cost
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Whose Fault
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yours or the other driver
Whose Fault
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Date of Ticket
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estimated date when you paid the ticket
Date of Ticket
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Location
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city and state
Location
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Charge
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following too close, speeding, improper lane change, careless & prohibited, failure to yield,etc
Charge
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Was Ticket Paid
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yes or no
Was Ticket Paid
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Have you ever had a DUI or DWI?
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Never
Yes
More than 1
Most recent DUI or DWI offense
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Show date of conviction: mm/yy & show city, state
Additional DUI's or DWI's:
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Show conviction date: mm/yy & city & state
Education
High School Grad?
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Yes
No
High School Grad?
How Many Years of College?
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1 year
2 year
3 year
4 year
Post Grad Work
Military Service
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Yes
No
Dates of Service
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From: mm/yy thru mm/yy
Type of Discharge
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Honorable, General, Medical, Dishonorable, other
Branch of Service
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Air Force
Navy
Marine Corp
Army
Coast Guard
Applicant Notice To Be Read And Signed By Applicant
I certify that I personally completed this application and all of the information is true and correct. I authorize Mid-America Truck Driving School, Inc, or their agents to obtain any and all information from previous employers, criminal checks and HireRight investigative services or, other consumer reports, in accordance with state and federal laws. Furthermore, I give my express consent for Mid-America Truck Driving School Inc, any previous employer, their agent or, Medical Review Officer or, their agent to release information concerning any of my past controlled substances test results. I understand that false or misleading information will disqualify me from further consideration and I am subject to immediate termination if this becomes known after enrollment. I authorize my previous employers to release any information required by Mid-America Truck Driving School, Inc and hold them harmless of all liability for the release of said information.
Choose One
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I ACCEPT the terms of this Applicant Notice
I DO NOT Accept the terms of this applicant Notice
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