1ACE TRAINING CENTER, Inc.

JOB FITNESS SURVEY

STUDENTS NAME (PRINT)______________________________________________________ Date ____________
First Middle Last

1. I understand that this training is to prepare me for the job for OVER THE ROAD Truck Driving and that I will be away from
home for two to three weeks at a time. Yes ____ No _____

2. Certain medications will affect your ability to drive. Are you taking any medication: Yes ____ No _____
If yes, list all medications that you are taking: ______________________________________________________________
___________________________________________________________________________________________________

3. Are you a diabetic, if yes, are your diabetes medications: ____ Oral, or ___Injections Yes ____ No _____
If you are a diabetic how long have you been on your current medication? _____________________________________

4. Do you have high blood pressure, Yes ____ No _____

If you are on blood pressure, is your blood pressure controlled by medication? Yes ____ No _____

5. Do you have 20/40 or better vision in both eyes, even if you use corrective lens? Yes ____ No _____

6. Have you ever had an eye injury? Yes ____ No _____

If yes, explain what happened: _______________________________________________________________________

7. Do you have any physical defects? Yes ____ No _____

If yes, what physical defects do you have:_______________________________________________________________

8. Have you had any surgeries in the last ten years? Yes ____ No _____
If yes, what surgeries have you had and when? __________________________________________________________
_______________________________________________________________________________________________

9. Do you have any hearing loss in either ear? Yes ____ No _____

10. Do you understand that you will be subject to random drug and alcohol testing the entire time that you are in this career that you
are choosing to pursue? Yes ____ No _____

11. Do you understand that certain drugs stay in your system for over 8 weeks and a hair follicle test will show substance abuse
within the last four to six months? Yes ____ No _____

12. Will you be prepared to take a DOT Physical before entering school? Yes ____ No _____

13. Do you feel that you can pass a drug screen before coming to school? Yes ____ No _____

14. Are you currently drawing any form of assistance from any branch of the government? Yes ____ No _____
If yes, what type of assistance do you receive? ___________________________________________________________

15. Do you understand the physical requirement of the job? Yes ____ No _____

16. Are there any reasons that you feel that you cannot do this job? Yes ____ No _____
If yes, what reason : ___________________________________________________________________________________

17. Have you ever failed a drug or alcohol test with any employer? Yes ____ No _____
If yes, what company and what year: _____________________________________________________________________

18. Are you under a court order to pay child support? Yes ____ No _____
If yes, are you current? Yes ____ No _____
If you are behind, how far are you behind? ________________________________________________________________
 STUDENT DRIVER REFERENCE SHEET
NAME___________________________________________________ PHONE___________________________________

SOCIAL SECURITY # _________-________-__________ HEIGHT ______________ WEIGHT _____________

YOUR EMAIL ADDRESS: ____________________________________________________________________________

CURRENT ADDRESS_________________________________________________________________________________
Address City State Zip Code

How long have you lived at this address?_______________________________

PREVIOUS ADDRESS________________________________________________________________________________
Address City State Zip Code
DATE OF BIRTH________________ DRIVERS LICENSE # ____________________________ STATE ___________

NEAREST RELATIVES NAME & ADDRESS (For emergency Use) PHONE NUMBER

1._________________________________________________________ _(_____)_____________________

Address ___________________________________________________________________________________________

2._______________________________________________________ _(_____)_____________________

Address __________________________________________________________________________________________

EDUCATION Circle the highest grade completed 12345678 High School 1 2 3 4 College 1 2 3 4

I graduated from __________________________________ High School in the year of__________ In what state?_________

I have a GED, from ________________________________________in what year?__________ In what state?___________

I attended college, (last college attended) __________________________ in what year?__________ In what state?___________

INVITATION TO IDENTIFY:

To comply with government regulations and reporting requirements, we request that you complete the VOLUNTARY DATA FORM :
I wish to be considered under the Affirmative Action Program as a :
☐ Male ☐ Female
☐ I am a U. S. Citizen ☐ I am not a U. S. Citizen ☐ I am a Naturalized U. S. Citizen
☐ American Indian or Alaskan Native : A person having origins in any of the original people of North America.
☐ Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the
Pacific Islands.
☐ Black: A person having origins of any of the original peoples in any African country.
☐ Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish origin.
☐ Unlisted: Please give nationality ______________________________________________________________
☐ White
☐ Disabled Veteran: A person entitled to or receiving disability compensation through the Veteran’s Administration.
☐ Disabled: Any person who has a physical or mental impairment which substantially limits one or more of the individual’s major
life activities, so as the individual is likely to experience difficulty in securing, retaining, or advancing in employment.
* Refusal to provide data will not subject you to any adverse treatment. By voluntarily providing the above information, I fully understand that it will be
confidential.

ACE TRAINING CENTER, INC.

 DRIVER TRAINEE ENROLLMENT FORM
Please print clearly
NAME:_____________________________________________________________ DATE:_____________________
First Middle Last

DATE OF BIRTH: ________________________ SOCIAL SECURITY NUMBER: ____________________________

PHONE NUMBER (S): _(_______)________________________ _(_______)________________________________

DRIVERS LICENSE NUMBER: ____________________________________ STATE:_____________

1. Have you ever been charged or convicted for careless or reckless driving? Yes ____ No _____
When and why ?
_________________________________________________________________________________________________

__________________________________________________________________________________________________

2. Have you ever been charged with driving under the influence of alcohol or a controlled substance? Yes ____ No _____
If so give dates and what county and state were the charges were received. _____________________________________

____________________________________________________________________________________________________

3. Has any license, permit or privilege ever been suspended or revoked? Yes ____ No _____
When, why and for how long were you suspended?__________________________________________________________

___________________________________________________________________________________________________

4. List ALL States and drivers license numbers where you have held a drivers license in the last 10 years.
State License No. Type and Endorsement Expiration Date
___________________________________________________________________________________________________

___________________________________________________________________________________________________

5. Have you had any tickets in the last 5 years? (Wether you have paid them or not) Yes ____ No _____
If so give dates, locations, and what the ticket was for :
City State Date Charge Fine paid or Not paid
___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

6. Have you ever had a felony charge or been incarcerated? Yes ____ No _____
Please Explain: ___________________________________________________________________________________

___________________________________________________________________________________________________

7. Have you ever had a misdemeanor charge or been incarcerated? Yes ____ No _____
Explain: ________________________________________________________________________________________

___________________________________________________________________________________________________

8. Do you have any other charges pending? Yes ____ No _____

Explain: _________________________________________________________________________________________
 ACE TRAINING CENTER, INC.
P. O. BOX 720429 * JACKSON, MS 39272
PHONE 1-888-430-4223 * FAX 1-601-502-0740

DISCLOSURE AND RELEASE STATEMENT

In connection with my application as a student of Ace Training Center, Inc, I understand that consumer reports which may contain
public record information may be requested from previous employers, financing agencies, credit reporting agencies, the Office of
Motor Vehicles, and various county, state, and federal reporting agencies. These reports include the following types of information:
names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand
that such reports may contain public record information including my driving record, worker’s compensation claims, credit,
bankruptcy proceedings, criminal records, etc., from federal, state and various other reporting agencies which maintain such records;
as well as information from HireRight Solutions, Informus/Choice Point, TransUnion, Partners Financial Services Inc., etc.
concerning previous driving record requests, background check requests, and credit history requests made by others from such local
agencies and records, state agencies, schools, colleges and state provided records, and federal agencies and records, etc. Information
about HireRight’s privacy practices is available at: www.hireright.com/Privacy-Policy.aspx.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY ANY REPRESENTATIVE

OF ACE TRAINING CENTER, INC. TO FURNISH THE ABOVE-MENTIONED INFORMATION.

I have the right to make a request to any credit reporting agency, upon proper identification, to request the nature and substance of all
information; and the recipients of any reports on me which any agency has previously furnished within the last two year period
preceding my request. I hereby consent to your obtaining the above information from Informus and or Trans Union, and I agree that
such information which any reporting agency has or obtains, and my employment history with you if I am hired, will be supplied by
them to other companies which subscribe to any reporting agency.

I hereby authorize procurement of consumer report{s}. If accepted for training, this authorization shall remain on file and shall serve
as on going authorization for you to procure consumer reports at any time during my contract period.

Print:
_____________________________________________________ ______________________________________
Printed First Name Middle Name Last Name Social Security Number

_____________________________________________ _______________________________
Applicant’s Signature Date

Any other names used (alias, maiden, married, etc.) _________________________________________________________

Please Print Clearly:

Date of Birth : _____/_____/_____ Driver’s License # : _____________________________ State : _______________

Address:____________________________________________________________________________________________

City: _________________________________________ State: _____________ Zip Code: ______________

Phone # : ___________-___________-_______________ 2nd Phone # : ___________-___________-______________

Your E-Mail Address: _________________________________________________________________________________

 COMPLETE EMPLOYMENT RECORD FOR PAST 10 YEARS
EXPLAIN ALL GAPS IN EMPLOYMENT (ATTACH SHEET IF MORE SPACE IS NEEDED)

NAME: _________________________________________ SOCIAL SECURITY: ___________-__________-__________

Current or Last Employer Name : __________________________________________________________Position held :_______________________________________________

Address:______________________________________________________________________________Salary________________________Phone :________________________

From : Mo. __________ Yr. __________ To: Mo. __________ Yr. __________ Reason for Leaving : __________________________________________

Previous Employer Name:_________________________________________________________________Position held:______________________________________________

Address:_______________________________________________________________________________Salary_______________________Phone:________________________

From : Mo. __________ Yr. __________ To: Mo. __________ Yr. __________ Reason for Leaving : __________________________________________

Previous Employer Name:_________________________________________________________________Position held:______________________________________________

Address:_______________________________________________________________________________Salary_______________________Phone:________________________

From : Mo. __________ Yr. __________ To: Mo. __________ Yr. __________ Reason for Leaving : __________________________________________

Previous Employer Name:_________________________________________________________________Position held:______________________________________________

Address:_______________________________________________________________________________Salary_______________________Phone:________________________

From : Mo. __________ Yr. __________ To: Mo. __________ Yr. __________ Reason for Leaving : __________________________________________

Previous Employer Name:_________________________________________________________________Position held:______________________________________________

Address:_______________________________________________________________________________Salary_______________________Phone:________________________

From : Mo. __________ Yr. __________ To: Mo. __________ Yr. __________ Reason for Leaving : __________________________________________

Previous Employer Name:_________________________________________________________________Position held:______________________________________________

Address:_______________________________________________________________________________Salary_______________________Phone:________________________

From : Mo. __________ Yr. __________ To: Mo. __________ Yr. __________ Reason for Leaving : __________________________________________

Previous Employer Name:_________________________________________________________________Position held:______________________________________________

Address:_______________________________________________________________________________Salary_______________________Phone:________________________

From : Mo. __________ Yr. __________ To: Mo. __________ Yr. __________ Reason for Leaving : __________________________________________

Previous Employer Name:_________________________________________________________________Position held:______________________________________________

Address:_______________________________________________________________________________Salary_______________________Phone:________________________

From : Mo. __________ Yr. __________ To: Mo. __________ Yr. __________ Reason for Leaving : _________________________________________
_
NAME : ____________________________________________________________________________ SOCIAL SECURITY # : ____________-__________-____________

Previous Employer Name:_________________________________________________________________Position held:______________________________________________

Address:_______________________________________________________________________________Salary_______________________Phone:________________________

From : Mo. __________ Yr. __________ To: Mo. __________ Yr. __________ Reason for Leaving : __________________________________________

Previous Employer Name:_________________________________________________________________Position held:______________________________________________

Address:_______________________________________________________________________________Salary_______________________Phone:________________________

From : Mo. __________ Yr. __________ To: Mo. __________ Yr. __________ Reason for Leaving : __________________________________________

Previous Employer Name:_________________________________________________________________Position held:______________________________________________

Address:_______________________________________________________________________________Salary_______________________Phone:________________________

From : Mo. __________ Yr. __________ To: Mo. __________ Yr. __________ Reason for Leaving : __________________________________________

Previous Employer Name:_________________________________________________________________Position held:______________________________________________

Address:_______________________________________________________________________________Salary_______________________Phone:________________________

From : Mo. __________ Yr. __________ To: Mo. __________ Yr. __________ Reason for Leaving : __________________________________________

REFERENCES :

1. NAME __________________________________________________________________________________________________

ADDRESS : ________________________________________________________________________________________________

PHONE # : _________________________________________________________________________________________________

2. NAME __________________________________________________________________________________________________

ADDRESS : ________________________________________________________________________________________________

PHONE # : _________________________________________________________________________________________________

3. NAME __________________________________________________________________________________________________

ADDRESS : ________________________________________________________________________________________________

PHONE # : _________________________________________________________________________________________________
 ACE TRAINING CENTER
P. O. BOX 720429 * BYRAM, MS 39272-0429
PHONE 601-502-0730 * FAX 601-502-0740

APPLICATION PREPARATION
In order for any company to process your application for employment, it is important that several items are included with the
application or stated on the application. Bottom line you are here so that you can get a good job making good money. In order to
achieve that goal there are certain guidelines that must be followed, and they are as follows:

• To get your CDL License you will have to be able to pass a D.O.T. Physical. List all of your medications and your physical
limitations on your application. Explain each limitation fully.

• Please note, You WILL be required to pass a drug screen and a DOT Physical before entering school.

• Please read the entire application, before completing it and be sure to do the front and back of each page. Complete all blanks or
spaces and answer all questions. Incomplete documentation or work history can prevent you from getting a job.

• Provide at least 4 different references, including area codes, phone numbers, city, and state.

• List all driver’s license you have held in the past 5 years and include the state, license number, type, and expiration date.

• List 10 years of employment history. Include all periods of unemployment, military service, college, trade schools and/or high
schools, just like you would an employer. List any periods of unemployment of more than 30 consecutive days, just like an
employer. Be specific on dates of employment month and year are acceptable. Include phone #s with area codes on all
employers. If you cannot remember an employer’s address, you must provide the name of city and state.

• Unemployment periods in which you collected unemployment benefits must be accompanied by a print out of benefits received
including the beginning and ending dates of benefit period. You must also include a Declaration of Employment Status Form,
explaining how you were supported during this time.

• Self-employment periods must be accompanied by tax forms, (1099 or Schedule C - Profit and Loss Statements). If you cannot
provide tax forms, you must provide 3 reference letters on business stationary (i.e. - banker, accountant, suppliers, and / or other
people with which you conducted business).
• Reference letters must be specific on dates and include phone #s for verification and be notarized.

• If you have worked for a company that has gone out of business, provide one of the following information as proof. W-2 tax
forms, Social Security office computer printout, or check stubs. If you cannot provide tax forms you must provide 3 reference
letters, preferably on business letterhead as describe for self-employment.

• College / Trade School periods must be accompanied by transcripts, but they can be unofficial transcripts.

• Accidents which occurred during the last 3 years must be accompanied by accident reports.

• Military experience periods must be accompanied by DD214 (long form #4 with narrative at bottom).

• Date and sign the application in ALL of the proper places.