Official SDIA Student Application for Driving School

Safe Drivers Institute of America, LLC 1310 S. West Street Indianapolis, IN 46225 Telephone: 317-260-5104 Fax: 317-260-5105

Please Print Neatly and Answer All Questions

Part I. Personal Information Name: Last______First______Middle______List any other names by which you have been identified, first or last names. (Example: maiden name, nick name, etc.)______Social Security Number______Birth Date (MO/DA/YEAR)______Marital Status: ( )Married ( )Single ( )Divorced ( )Separated ( )Widowed Gender: ( )Male ( )Female Current Address: Street______City______State______Zip______How Long?______Previous Address: Street______City______State______Zip______How Long?______Email Address: ______Home Phone: ______Cell Phone: ______Race: ( )Black ( )White ( )Hispanic/Latino ( )Asian ( )Native American Indian ( )Other Citizenship: ( )U.S. Citizen ( )Permanent Resident Alien ( )Other If you specified “other” under citizenship above, please explain______

Language: DOT Requirement/FMCSR/Part 390/Subpart B/Section 391.11 (b) (2) states a driver must be able to 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.

1 ( )English Language ( )Other If “other”, list your native language here______DOT Requirement/FMCSR/383.71/part vii states you MUST provide the names of ALL States where you have been licensed to drive ANY type of motor vehicle during the previous 10 years. ______

Part II. Education/Military Experience Did you earn your High School Diploma or GED? ( )Yes ( )No Highest Grade Completed: 1 2 3 4 5 6 7 8 High School: 9 10 11 12 College: 1 2 3 4 Name of Last School Attended______City/State______

Military Branch______From______To______Highest Rank______Discharge Date______Specialty______

Part III. Health/Well Being Can you pass a DOT physical? ( )Yes ( )No Can you pass a drug test? ( )Yes ( )No Do you wear glasses/contacts? ( )Yes ( )No Do you have any heart conditions? ( )Yes ( )No Do you have high blood pressure? ( )Yes ( )No Do you have epilepsy? ( )Yes ( )No Do you have Diabetes? ( )Yes ( )No Do you have trouble hearing? ( )Yes ( )No Please list any prescription medications you are currently taking______

Part IV. Character History/Driving History Have you ever had a felony conviction? ( )Yes ( )No If “yes”, list details below. Date/Description______Are you currently on parole? ( )Yes ( )No If “yes”, since what date?______If “yes”, date of parole release?______

Provide 2 Personal Character References below. List their name, address, phone number AND relationship to you or how they know you. Reference #1______Reference #2______

Part V. Current Employment & 10 Year Employment History Are you currently employed? ( )Yes ( )No Occupation______Full-Time ( ) or Part-Time ( )

2 (Please list all jobs for the past 10 years, starting with the most recent job first. Use the back of the paper if more room is needed.) Employer Name______Dates FROM______- TO______Address______Contact Person______Phone______Position Held______Reason for Leaving______

Employer Name______Dates FROM______- TO______Address______Contact Person______Phone______Position Held______Reason for Leaving______

Part VI. Driving Experience/History & Qualifications Do you have a valid Driver’s License? ( )Yes ( )No Do you have a valid Class C - Driver’s License? ( )Yes ( )No Have you ever had a Commercial Driver’s License–Class A or B? ( )Yes ( )No If yes”, type(s) of vehicle(s) you have experience driving.______How long ago did you drive these types of vehicles?______Have you taken any driving courses before? ( )Yes ( )No Where?______Have you ever had a DUI or DWI? ( )Yes ( )No Have you ever had a ticket for reckless driving? ( )Yes ( )No Have you ever had your license suspended? ( )Yes ( )No If “yes”, explain below. ______Have you ever had your license revoked? ( )Yes ( )No If “yes”, explain below. ______Have you had any warning tickets in the last 3 years/excluding parking violations? ( )Yes ( )No Have you had any accidents in the last 5 years? ( )Yes ( )No Have you had any moving violations in the last 5 years? ( )Yes ( )No Have you ever been arrested/convicted for possession/sale/use of illegal drugs? ( )Yes ( )No Have you ever been convicted of a crime? ( )Yes ( )No Have you ever been convicted of an offense involving drugs or alcohol? ( )Yes ( )No Have you ever tested positive for drugs or alcohol? ( )Yes ( )No

If answered “yes” to any of the 7 items above, give detailed explanation(s) below, including year occurred.

3 ______Do you currently have a Valid Indiana CDL-Learner’s Permit? ______NOTE: You will be required to have this prior to the first day of class.

VII. Referral Source How did you hear about us? ______

Please list name(s) and phone number(s) below of anyone you know of who is interested in CDL training and whom you would like for us to send information to about our school. ______

VIII. Emergency Information Emergency Contact -- First/Last Name ______Phone Number for Emergency Contact ______IX. Background Check and Motor Vehicle Report (MVR) SDIA will conduct a Background Check and pull a current MVR on all applicants. X. First Day of Class – Students accepted & enrolled into the SDIA program will need to have the following items with you. -CDL Permit - Your Class A Permit is REQUIRED upon the first day of class! -DOT Physical completed and you must have the entire Physical Form with you -Drivers License

PROGRAM DETAILS -SDIA is an Indiana State Licensed Truck Driving School -Classes typically run Monday through Friday, 8:00am – 5:00pm (Class dates/times may be adjusted to accommodate for any unforeseen circumstances.) -Classes will be held at 1310 S. West Street, Indianapolis, IN 46225 -Program is about 5 weeks long (5th week is used for more driving and for taking your State CDL Test.) -Program consists of 162 hours 118 hrs Classroom/Lab 44 hrs Range & Road -Daily combination of all activities most days -Job Placement Assistance -Course curriculum from Professional Truck Driver Institute (PTDI) -Program includes Safety Training & Forklift Training at no additional cost! -Our range and road training include all required truck driver training as well as several items most other programs do not include. Some of these items are: Coupling & Uncoupling, Backing to LIVE Docks & Docking Procedures, 48’ & 53’ Trailers, Day-Cab & Sleeper Truck Training, One on One Road Training and more!

Student Applicant Acknowledgement

I certify all answers given in this application are complete and accurate to the best of my knowledge. I understand submission of false information may result in my denial or disqualification for enrollment to Safe Drivers Institute of America, LLC (SDIA). I agree to abide by the rules and regulations set forth by SDIA. I authorize SDIA to verify any information provided, including employment verification, reference checks, criminal record and/or motor vehicle record and obtaining any educational records or transcripts. If applicable, and I have applied for tuition financing, SDIA is authorized to conduct the necessary credit check. Any untrue or misleading information may be basis for denial of admission, disqualification from employment by any employer or job placement assistance by SDIA. I recognize training for and working in the trucking industry with heavy equipment can be dangerous and may cause injuries. I assume the risk, I accept full responsibility for this situation and I hereby release and indemnify SDIA from any and all claims, actions, suits, liabilities, judgments and proceedings arising in whole or in part from my acts or omissions related to attending SDIA. I understand this application does not obligate me to enroll in the SDIA program, nor does it guarantee my acceptance into the SDIA program or its services. I acknowledge enrollment in and/or graduation from SDIA’s truck driving program is not an offer for or a guarantee of employment. Further, I understand, “An owner, officer, instructor, agent or employee of any truck driver training school shall not state nor give the impression to a student that upon completion of the course, they will guarantee the securing of a commercial driver’s license to operate a commercial motor vehicle”.

Student/Applicant Signature______Date______

Printed Name______