IITR Truck Driving School - Enrollment Questionnaire 2008

Driving Directions to:
Portland Campus
Eugene Campus
Medford Campus
Bend Campus
Albany Campus

Eugene/Albany/Medford
1-800-976-7612
541-895-5525

Pre-Enrollment
Questionnaire

Please Fill out entirely

First Name:
Last Name:
Age:
Home Phone Number:	(ex. 503-123-4567 )
Email:
Home Address:
City:
State:
Zip Code:

Please answer the following questions. If your answer is yes to any question, please explain in the space provided.

01) How many moving violations have you been convicted of in the last 5 years?
None At Least One or More If At Least One or More, you must explain:


02) Have you been involved in more than 1 accident in the past 5 years?
No Yes If yes, how many and were they your fault?


03) Have you been convicted of any major violations in the last 5 years? (careless, negligent, reckless, hit & run, eluding, etc.)
No Yes If yes, you must explain:


04) Do you have any alcohol-related violations (breath failure, DUI, DWI, MIP, Diversion, etc.) in the last 5 years, or have you ever had more than 1?
No Yes If yes, you must explain:


05) Has your driver's license been suspended or revoked in any state in the last 5 years?
No Yes If yes, you must explain:


06) Do you have any felony or misdemeanor convictions?
No Yes If yes, when and what for?


07) Do you have any difficulty reading, writing, or understanding English?
No Yes If yes, you must explain:


08) Do you currently have or have you ever had any physical problems such as a bad back, neck, leg, etc., or do you have any of the following problems: vision problems in either eye, diabetes, hearing problems, epilepsy, high blood pressure, or lifting limitations? (You must pass a DOT physical and NIDA drug screen)
No Yes If yes, you must explain:


09) Is driving a vehicle with a clutch a new experience to you or do you anticipate it being a problem?
No Yes If yes, you must explain:


10) If you are old enough are you able to provide your 10 year work history?
No Yes If no, you must explain:


All potential students must understand that a bad work history, driving record, criminal background, physical problems, mental or social problems, will limit your employment opportunities as a tractor-trailer driver.

11) What source of advertisement brought you to IITR?
If other:

12) What is your previous employment experience? (what have you done)


13) What is your educational background? (IITR students are required to provide proof)
High School Education If other: Number of years of College

14) What type of employment do you desire if you attend and graduate from IITR?


15) If I attend, I plan to pay my tuition by the method checked below:
Additional Explanation:

16) My Credit is: (only for those applying for a Loan)

If you have poor credit can you obtain a cosigner? No Yes

17) COMMENTS - If you have spoken with an IITR representative, please detail this conversation below.


18)Mandatory questions required by our Licensing Agencies
Are you a U.S. Citizen or have proof of your Legal Right to Live or Work in the U.S?


Race: If other, please fill in below:
Final e-mail Verification - Please re-enter your e-mail address.
Gender: Male Female