Excellence In Training
Student Enrollment Application
Personal Data
Name
Last
First
M.I.
Address
City
Street
State
Zip
Phone
Email
Mobile
Home
Drivers License #
Date of Birth
Primary Language
When would you like to start?
What program are you applying for?
Driving History
Have you ever taken any of our courses before?
If yes, please describe
Do you have a valid Class C license?
Have you ever had a Commercial Driver License ( Class A or Class B)?
If yes, type of vehicle and how long ago?
Do you have a current learners permit?
Any issues on your driving record that may be of concern?
If yes, please list (Time of occurrence(s) and nature of occurrence(s)
Please complete accurately and truthfully so that we can properly help you.
Work History-  Please list the last company and location that you worked for (If self employed please
state that in the box below.  This helps with job placement.)
Criminal Background-  Please complete accurately and truthfully so that we can properly help you.
Any criminal issues within the past 10 years?
(This does not exclude you from training but allows us to best assist with job placement.)
If yes, please list (Time of occurrence(s) and nature of occurrence(s)
Physical & Health Conditions   Please complete accurately and truthfully so that we can properly help you.
Are you taking any medication or have any medical or health issues?
If yes, please explain ( This does not automatically exclude you from training)
Education Documentation
Which of the following do you have?  ( Choose One)
Referral Source
How did you hear about us
Payment Options
Are you paying the tuition yourself ?
Do you need financial assistance?
If yes, one of the following agencies may be able to cover tuition costs.  Contact our office for additional options
Are you working with a tuition assistance agency ?
If, yes contact Person
Phone
Name   
Do you have any employment  or travel limitations that we should be aware of ?       
(Examples.- Must work within 50 miles. Unable work for certain companies or in specific industries)
If yes, Please provide details so that we can better assist you.
Please provide any additional notes or comments that can help us better assist you.
Emergency Contacts-**
Phone
Name   
Phone
Name