Western Pacific
Truck School of Oregon

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Application Form

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Pre-Enrollment Application

Personal Information
First Name
Middle Name
Last Name
Date of Birth
Address
City
State
Zip
Phone Number
Email address
How did you heard about us?	Billboard Friend Internet Search Referral Other Radio Ad TV Ad
If "Other" Please specify

Education
High School Diploma	Yes No
GED	Yes No

Background Information
If accepted, can you provide proof that you are eligible to work in the United States?		Yes No
Can you read and speak the English language sufficiently to converse with the general public, to understand highway traffic signs and signals in the English language, to respond to official inquiries, and to make entries on reports and records?		Yes No
Have you ever been convicted of a misdemeanor?		Yes No
Have you ever been convicted of a felony?		Yes No
If "Yes" Please specify
Are you currently on probation or parole?		Yes No
Do you have "ANY" moving violations or accidents in the last 5 years?		Yes No
Have you been convicted in the last 5 years of Reckless, Negligent, or Careless Driving?		Yes No
Have you EVER been convicted for driving while intoxicated?		Yes No
Have you ever had your driver's license suspended or revoked?		Yes No
Do you have any history of epilepsy, diabetes, or high blood pressure?		Yes No
Do you have any heart or cardiac problems?		Yes No
Have you had any major surgeries, knee or back, or have other limitations?		Yes No
Do you have any history of mental illness?		Yes No
Do you have any history of dyslexia?		Yes No
Do you have a poor work history or lack references?		Yes No