A.C.T. promises not to sell any of the information provided in this application. Information will be released to prospective employers only.

Action Career Training On-Line Application

Name:
Address:	City:
State:	Zip Code:
Phone:	E-Mail:
SS#:	Citizen: YES NO
	How did you hear about ACT? Friend Newspaper TV Ad Link Other

Personal History

	Date of Birth:
	Married Single # of Dependants:
	Military experience? YES NO
	How long (years)? Date Discharged:
	Type:
	Date of last physical: I certify, to the best of my knowledge, I am in good physical condition: YES NO

Background & Driving History

	Have you ever been convicted of a felony? YES NO
	Date of conviction: Nature of Conviction:
	Have you ever been convicted of a DUI/DWI? YES NO Date of Conviction:

Driver Licenses held in past 3 years must be shown.

State: License No. Class: Expiration Date:

State: License No. Class: Expiration Date:

State: License No. Class: Expiration Date:

# of moving violations in last 3 years:

1st Date: Nature:

2nd Date: Nature:

Accident Review for past 5 years:

Last Accident Nature of Accident:
	Fatalities Injuries
Previous Accident Nature of Accident:
	Fatalities Injuries

Educational History

Highest Grade Completed: 1 2 3 4 5 6 7 8 9 10 11 12 College 1 2 3 4

Diploma? YES NO GED? YES NO

Last school attended:

Employment Record

The U.S. Department of Transportation requires that driver applicants show all employment for the past three years. Effective July 1987, they must also show commercial driver employment for the seven years immediately preceding this three-year period.

Start with last or current position, including military experience, and work background.

Current Employer:

Supervisor's Name:

Address:

Phone:

Position Held:

From: To:

Salary:

Reason for leaving:

Previous Employer:

Supervisor's Name:

Address:

Phone:

Position Held:

From: To:

Salary:

Reason for leaving:

By submitting I hereby authorize, without liability, any person or organization whose name I have given as reference, or by whom I have been previously employed, to furnish Action Career Training any information they may have concerning my character, habits, financial responsibility, credit history, job performance, etc.

I hereby authorize any law enforcement agency or court of record to furnish Action Career Training any information concerning motor vehicle report, or any felony or misdemeanor of which I have been convicted. I authorize, without reservation, any or party or agency contacted by DAC to furnish the above mentioned information.

This certifies that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge. False, misleading, or incomplete statement of the information requested in this application shall be sufficient cause for termination from training.

Check all above information for correctness then submit below.