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(440) 236 - 3436

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Application for Training

Step 1 of 6

16%

First Name*
Last Name*
Social Security*
County*
Address*
Street Address Address Line 2 City State ZIP Code
Email Address*
Date of Birth*
YYYY dash MM dash DD
Age*
Phone Number*

Citizenship status*
- I Am A U.S. Citizen
- I Am An Eligible Non-Citizen
Alien registration number required
Race/Ethnicity*
- Asian/Pacific Islander
- American Indian
- Black/Non-Hispanic
- Hispanic
- Alaska Native
- White/Non-Hispanic
- Unknown
Marital status*
- Married
- Single
- Separated
- Divorced
Gender*
- Male
- Female
My license number*
Type(s) of licenses*
State(s) where licensed*
Have you held a driver's license for at least 2 years?*
- Yes
- No
Distance to travel to our school*
- 0-15 Miles
- 15-25 Miles
- 20-50 Miles
- 50 Miles or More

Education (check all that apply)*
- High School Graduate
- GED
- Home School
- Degree
If you responded "High School Graduate", please provide the following information about your school:*
Name City State
Are you a veteran?*
- Yes
- No
Demographic area*
- Urban (over 100,000)
- Suburban (25,000 to 100,000)
- Rural (under 25,000)
Currently Collecting Unemployment Benefits?*
- Yes
- No
End date of unemployment benefits
MM slash DD slash YYYY
Are you prepared to accept employment Immediately upon graduation?*
- Yes
- No
Are you interested in Heavy Equipment Training?*
- Yes
- No
- Need more info

Emergency Contact 1
Name*
Relationship*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Emergency Contact 2
Name*
Relationship*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Notes

Work History
Company Name*
City*
State*
From*
YYYY dash MM dash DD
To*
YYYY dash MM dash DD
Company Name*
City*
State*
From*
MM slash DD slash YYYY
To*
YYYY dash MM dash DD
Company Name
City
State
From
YYYY dash MM dash DD
To
YYYY dash MM dash DD

License #
Type
State Where Licensed
License #
Type
State Where Licensed
License #
Type
State Where Licensed
License ever revoked or suspended?*
- Yes
- No
Reason?*
Moving Violations in past 3 years?*
- Yes
- No
Explain*
Speeding Violations in past 3 years?*
- Yes
- No
Explain*
Accidents in past 3 years?*
- Yes
- No
Explain*
DRUG / DUI / DWI Convictions ever?*
- Yes
- No
Month/Year*
Reckless Operation Convictions Ever?*
- Yes
- No
Month/Year*
Have you ever been convicted of a felony?*
- Yes
- No
Explain*
Have you ever been convicted of a Misdemeanor?*
- Yes
- No
Explain*
Medical Issues preventing you from passing a dot physical?*
- Yes
- No
Explain*
*Including, but not limited to, insulin-dependent diabetes, epilepsy, sleep apnea, certain medications, vision, or hearing problems.
In order to determine employment eligibility upon graduation from Great Lakes Truck Driving School (hereinafter referred to as School), I hereby authorize the School to conduct a pre-background investigation that will include information as to my driving and criminal record. I UNDERSTAND THAT PASSING THE PRE-BACKGROUND CHECK WILL NOT GUARANTEE ME A LICENSE OR EMPLOYMENT UPON GRADUATION. I hereby authorize any entity having information, control, or possession of any information pertaining to my driving or criminal record, if applicable, to release said information to the School. I further acknowledge that a facsimile or photocopy of this Release Authorization shall be as valid as the original. By this Authorization, I hereby forever release, discharge, exonerate, hold harmless and indemnify the School, its directors, officers, employees, representatives, agents, subcontractors, and independent contractors and any other person, entity, organization, or institution furnishing information to them from any and all liabilities of every nature and kind, including but not limited to claims for libel, slander, invasion of privacy, related tort claims, misuse of information obtained from the School and any other claim or cause of action arising out of the furnishing, inspecting, or copying of any documents, files, records, and other information, or the investigation made by or on behalf of the School, unless such release is determined to violate the public policy of the state or federal district where this contract is executed, and in that event, this release will be permitted to the maximum extent allowed by the governing law. Drug and alcohol testing is mandatory for employment in the trucking industry. Passing the Department of Transportation (DOT) physical & drug screen is required for admittance and will be done prior to start of class. Any student who fails the drug screen will not be admitted. Random drug and alcohol testing is a routine practice of the trucking industry and therefore, is a practice of Great Lakes Truck Driving School. By signing below, you are acknowledging that you understand you will undergo these tests in order to be admitted to the school, and the information you’ve provided in this application is accurate. Additionally, you give Great Lakes Truck Driving School permission to contact you regarding training and career information, as well as maintain your information in a central database accessible to hiring employers.
Date*
YYYY dash MM dash DD
*
- By submitting this, I understand that Great Lakes TDS may contact me about their educational services through various means at the information provided, including a wireless number, using an automated technology, telephone, email, text messaging and postal mail. This consent is not required to attend their institutions.
Signature*
Untitled
Number
Untitled
- First Choice
- Second Choice
- Third Choice

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27740 Royalton Rd.
Columbia Station, Ohio 44028 440-236-3436

(440) 236 - 3436

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