CDT School Confidential Qualification Chart

COMMERCIAL DRIVER TRAINING INC.
600 PATTON AVENUE
WEST BABYLON NY 11704
(631) 249-1330
cdtwb@aol.com
CONFIDENTIAL QUALIFICATION CHART
Your Name*
First NameLast Name
Age*
Phone Number*
Address*
Street Address
Street Address Line 2
CityState
Zip Code
Date of Birth*
Your Email*
Social Security Number*
Required to acquire driving record
Driver’s License Number
NYS Only
Are You Being Sponsored By An Agency Or Company?*
Choose Agency*
If Yes, List The Agency/Company, The Name And Phone Number Of Your Contact
Required to determine if you will meet DOT (Dept. of Transportation) medical requirements
Are You Diabetic? *
Are You Epileptic?*
Any Loss Of The Following?; Foot/Feet, Leg(s), Arm(s), Finger(s)*
Are You Currently On Any Medications?*
If YES, please list the name(s) and what they are being taken for
Has Your License Ever Been Suspended or Revoked?*
When/Why?
Are You Able To Speak, Read And Write In The English Language? *
Do You Have A Police Record? *
If Yes, Please Fill Out The Below Information
Conviction Date(s)
Crime(s) Convicted Of (Include If Felony Or Misdemeanor)
Were you sentenced to serve time? *
If Yes, How Long?
Were/Are You Currently On Probation Or Parole? *
If Yes, How Long (Months/Years) & List the Month/Year That It Ended Or Will End?
Please review the above application. If correct and complete, type your full name and put today’s date below then submit. Our office will receive, review and contact you to discuss our offered courses that are available. Please be advised that due to COVID-19, we are currently working from home until further notice and will contact you when we can. We thank you for your interest in our school and for your understanding during this time.
I understand that you will be requesting information concerning my driving record and/or information from various federal, state, and other agencies which maintain records concerning traffic offenses, accidents, etc. I hereby consent to this, and that my application and my grades attained in resident training be submitted to interested companies or to personnel and safety people who are interested in hiring me. I hereby consent to you obtaining the above described information. I hereby release Commercial Driver Training from any claims or damages of any kind which may occur by reasons-of-employment with a company that may have been given as a job lead by our Placement Department.
Name*
Today’s Date*
MonthDayYear
1
Signature*
Clear
Should be Empty:

COMMERCIAL DRIVER TRAINING INC.

600 PATTON AVENUE WEST BABYLON NY 11704 (631) 249-1330cdtwb@aol.com

CONFIDENTIAL QUALIFICATION CHART

Required to determine if you will meet DOT (Dept. of Transportation) medical requirements

600 PATTON AVENUE
WEST BABYLON NY 11704
(631) 249-1330
cdtwb@aol.com