Please direct this application to the attention of...
Personal Information
* Name:* Address:* City:* State:* Zip:* How long at this address:Previous Address: Required if less than 3 years at current address.
City: State: Zip * Telephone:Cell Phone: * Social Security#:* Age:* Date of Birth:* Your Email address:* Referred by:* Driver's License #:* Type:* State:* Expiration:U.S. Citizen or National? Yes No
-(or)- Eligible Non-Citizen or Permanent Resident? Yes No
Program Interested In: 180 Hour Truck Driver Program 70 Hour Bus/Truck Driver Program
Will you be needing Georgia Driving Academy's assistance in obtaining a student loan? Yes No
Based on your observation of the trucking industry, which of the following types of driving
would you be willing to accept? Local Regional Long Distance
Driving/Criminal Record
In which states have you held a license in the last 7 years?
List the license numbers for each state above:
Has your license ever been suspended, canceled or denied? Yes No If yes, when? How many violations have you had in the past 7 years? Explain: How many at-fault accidents in the past 7 yrs? Have you ever been convicted of a DUI? Yes No If yes, when? If yes, how many? Have you ever been convicted of a felony? Yes No If yes, give year and type of charges: Have you ever been convicted of a misdomeanor? Yes No If yes, give year and type of charges: Have you ever been incarcerated? Yes No If yes, date entered? If yes, date released? Are you currently on parole or probation? Yes No Completion Date? Restricted? Any pending felony or misdemeanor charges? Yes No Explain:
Your Health Information
Any physical disabilities or handicaps that would prevent you from passing
a DOT physical? Yes No Any current medical restrictions? Yes No Explain: Have you been under a doctor's care in the past two years? Yes No Explain: List any medications currently taking: Filed a Workers Comp claim in past 5 years? Yes No Date claim settled:
Employment History
The following information must be completed for enrollment purposes and will be utilized only for official purposes. It will not be released or sold except as needed by school officials to complete your enrollment process.
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Current Employer: Address: Phone: Start Date: End Date: Position Held: Reason for leaving: -----------------------------------------------------------------------
Employer #2: Address: Phone: Start Date: End Date: Position Held: Reason for leaving: -----------------------------------------------------------------------
Employer #3: Address: Phone: Start Date: End Date: Position Held: Reason for leaving: -----------------------------------------------------------------------
Employer #4: Address: Phone: Start Date: End Date: Position Held: Reason for leaving: -----------------------------------------------------------------------
Employer #5: Address: Phone: Start Date: End Date: Position Held: Reason for leaving:
Education/Military Information
Do you have a high school diploma or GED? Yes No Highest grade completed: Have you ever attended a college, trade or technical school? Yes No Military service branch: Type of discharge: Served from: Served to: Are you receiving Military assistance for your education? Yes No
Your Financial Information
Have you ever filed for bankruptcy? Yes No If so, when? Other sources of income? Have you ever had a state or federal tax lien? Yes No
Are you behind in your child support payments? Yes No
If needed, do you have anyone willing to co-sign for a student loan? Yes No Who? Current rent or mortgage amount: Mortgage holder or landlord:
Personal References
Please provide accurate information. Do not list children who are currently living with you. A valid phone number and address for each of your personal references is necessary. Indicate if the reference may be willing to co-sign your student loan, if required.
First Family Reference: Second Family Reference: Third Family Reference: First Friend Reference: Second Friend Reference:
Domestic Information
Marriage Status: Married Single Divorced Separated Widowed Spouse's Name: Age: Number of Dependents: Spouse's Employer: How long: Present salary:
* Verify: type the digits from the blue boxFor the application to be submitted, you must enter the verification code.
In connection with my application for admission with GEORGIA DRIVING ACADEMY INC, I understand that consumer reports that may contain public recorded information may be requested from DAC Services, Tulsa Oklahoma, Experian, Allen Texas or TransUnion, Chicago Illinois. These reports may include the following types of information: name and dates of previous employers, reasons for termination of employment, work experience, accidents, credit and payment performance, etc. I further understand that such reports may contain public recorded information concerning my driving record, workers compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal state and other agencies which maintain such records, as well as information from DAC concerning previous driving records requested by others from state agencies and states providing driving records.
I authorize, without reservation, any party or agency contacted by DAC Services, Experian, or TransUnion to furnish the above-mentioned information.
I have the right to make a request to DAC, Experian Services or TransUnion, upon proper identification, to request the nature and substance of all information in its file on me at the time of my request. It shall include the source of information, and the recipients of any reports on me which DAC or Experian has previously furnished within the two year period preceding my request. I hereby consent that GEORGIA DRIVING ACADEMY, INC may obtain information from DAC, Experian & TransUnion, and I agree that such information which DAC or Experian has or obtains regarding me may be released to GEORGIA DRIVING ACADEMY, INC. Furthermore, if accepted by GEORGIA DRIVING ACADEMY, INC, I consent to the release of information to other companies that subscribe to DAC, Experian & TransUnion regarding performance with this Academy. This information shall include driving record, attendance, grades, curriculum delivered, and credit performance if financing is arranged.
I hereby authorize procurement of consumer report(s). If accepted, this authorization shall remain on file and shall serve as ongoing authorization for procurement of consumer reports at anytime during my training or duration of financial obligation.
IN ACCORDANCE WITH PUBLIC LAW 93-380 (BUCKLEY AMENDMENT), IF ACCEPTED FOR ENROLLMENT, I AUTHORIZE GEORGIA DRIVING ACADEMY, INC TO DISCLOSE INFORMATION FROM THIS APPLICATION AND/OR OTHER SCHOOL RECORDS TO PROSPECTIVE EMPLOYERS OR INTERESTED THIRD PARTIES FOR THEIR REFERENCE. I FURTHER AUTHORIZE GEORGIA DRIVING ACADEMY,INC. TO OBTAIN MY MOTOR VEHICLE DRIVING RECORD TO DETERMINE SUITABILITY FOR TRAINING. I CERTIFY THE INFORMATION I HAVE PROVIDED ON THIS APPLICATION IS TRUE IN SUBSTANCE AND IN FACT.
By submitting this application, I understand the misrepresentation or omission of facts called for is cause for dismissal or denial of entrance. All of the foregoing information is true and correct to the best of my belief and knowledge. I understand that it will be used only for determining the degree to which I may benefit from this training.
If any information contained in this application form is false, Georgia Driving Academy, Inc., in its sole discretion may decline to permit the applicant to participate in its free Job Placement Program.
