Division of Career and Community Education
107 Railroad Avenue / Elkton, MD 21921 / 410-287-1615 / Fax: 410-398-4429
Answer questions completely except for those which do not apply. Information is kept confidential. By enrolling in
this program, you grant permission to share your information with the Department of Labor, Licensing, and
Regulation (DLLR). This program reserves the right to check the accuracy of the information below.
APPLICATION FOR ADMISSION to TRUCK DRIVER TRAINING PROGRAM
Name:
(Last) (First) (M.I.)
Address:
(Street) (City) (State) (Zip)
Phone: (If no home phone, please give a number where we can leave a message.)
Email address: ___________________________________________________________
Social Security Number: Date of Birth:
Emergency Contact: Emer. Contact #:
Notification Preference: Email Text Message Phone
DRIVER’S LICENSE INFORMATION
Drivers License Number: Expiration Date:
State held: Endorsements:
Type of valid driver’s license you now hold: A B C D M
Have you been licensed in any other state(s) within the past 3 years? No Yes - State?
MILITARY SERVICE (U.S.)
Branch of Service:
Date Entered: Date Discharged: Honorable Discharge? Yes No
Military Job:
Highest Rank:
EDUCATIONAL BACKGROUND
Highest Educational Attainment (upon enrollment):
Elementary Middle School Some High School
High School Diploma Some College Associate’s Degree
Bachelor’s Degree Master’s Degree Doctorate
Do you currently hold an Industry Certification/Credential? Yes _____ No _____
If so, list certifications/credentials:
Additional skills:
Bi-lingual: Yes _____ No _____
Division of Career and Community Education
107 Railroad Avenue / Elkton, MD 21921 / 410-287-1615 / Fax: 410-398-4429
PREVIOUS EMPLOYMENT EXPERIENCE
Please provide most recent 3 years of job history, and 10 years if previous driver under FMCSA
regulations. Include times of unemployment and additional schooling. Begin with your most recent job
and work backwards. Add additional sheets, if needed.
Currently Unemployed:
From To:
Are you currently collecting Unemployment
Insurance: Yes No
Name of Current
Employer:
Telephone:
Address of
Employer:
Employment Dates (Month & Year): From:
To:
Supervisor (Name & Title):
Job Title (Brief Description of your duties):
Hourly Rate:
Fringe Benefits: Yes No
Reason for leaving:
Previous Unemployment: From To:
Name of Previous
Employer:
Telephone:
Address of
Employer:
Employment Dates (Month & Year): From:
To:
Supervisor (Name & Title):
Job Title (Brief Description of your duties):
Reason for leaving:
Previous Unemployment: From To:
Name of Previous
Employer:
Telephone:
Address of
Employer:
Employment Dates (Month & Year): From:
To:
Supervisor (Name & Title):
Job Title (Brief Description of your duties):
Reason for leaving:
Division of Career and Community Education
107 Railroad Avenue / Elkton, MD 21921 / 410-287-1615 / Fax: 410-398-4429
How did you learn of our program?
Have you ever pleaded guilty to or been convicted of any crime other than a traffic violation?
Yes No If yes, please explain:
Have you ever been convicted of a drug offense of any kind, including probation before judgment?
Yes No
If you answered yes to the either of the above two questions, please answer the following questions:
1. Are you on probation? Yes No
2. Number of convictions?
3. Date(s) of convictions:
Name of funding program you are applying under, if any:
Self Pay
Susquehanna Workforce Network
Vocational Rehabilitation
Delaware Dept. of Labor
Veteran’s Administration Programs
Other:
A current driving record from the Motor Vehicle Administration must accompany this application,
which can be obtained from your local Motor Vehicle Administration office or by going on-line.
I agree to submit to a DOT physical examination and drug testing upon acceptance of my
application. I understand that my application may be rejected for any false or incomplete statements
made on this application or for any other false or incomplete information given by me in connection
with it, including information relative to any physical or drug screen.
I certify that the information I have given on this application form is accurate and complete. I
understand it is my responsibility to notify the Workforce Training office of any change in the
information contained in this application. (If you have questions regarding this or any form, please
ask before signing.)
Signature Date
On your scheduled interview day, bring this application and copy of your driving record to:
Cecil College
Transportation and Training
107 Railroad Avenue, Room 206
Elkton, MD 21921
Division of Career and Community Education
107 Railroad Avenue / Elkton, MD 21921 / 410-287-1615 / Fax: 410-398-4429
TRUCK DRIVER TRAINING
DRUG AND ALCOHOL REGULATIONS
I understand that pre-admission requirements and continuation of training with Cecil College implies
my consent to submit to examination for the presence of unauthorized substances (drugs/alcohol) in
my body at any time prior to, during, or immediately after performing safety sensitive functions while
in school or in possession of school property, as a condition of training. I understand that the following
testing will be done in accordance with 49 CFR Part 382 and the Cecil College Alcohol and Controlled
Substances Testing Policy and Procedures:
1. Pre-admission testing
2. Post-accident testing
3. Random testing
4. Reasonable suspicion testing
5. Return-to-duty testing
6. Follow-up testing.
I understand that failure to honor these terms is grounds for denial of training or termination of
enrollment with Cecil College. This regulation became effective January 1, 1996, and is administered
by Cecil College. Please refer any questions to the Manager, Workforce Training.
Student Name (Please Print)
Student Signature Date
This page must be signed and returned prior to acceptance into the
TRUCK DRIVER TRAINING PROGRAM.
click to sign
signature
click to edit
Division of Career and Community Education
107 Railroad Avenue / Elkton, MD 21921 / 410-287-1615 / Fax: 410-398-4429
TRUCK DRIVER TRAINING
IMPORTANT INFORMATION
Please read the following information.
TRAINING SITE:
Your yard skills training will take place at the former Bainbridge Naval Training
Center site in Port Deposit, MD. Cecil College has been granted the use of a portion of
this property. If a student is found in an unauthorized area, the student could be
prosecuted and Cecil College could lose the use of the facility. All students must be in
sight of the instructor and under supervision at all times. Also, the danger of fire is very
prevalent at the training site. Smoking of any type is not permitted on the Bainbridge
grounds, in college vehicles, or on campus property. Do not discard any type of trash in
the grass, brush, or wooded area. These rules were specifically developed for building
and site preservation and student safety. Any student violating these rules is subject to
dismissal without refund of program tuition and/or fees.
Toilet facilities are provided. Please use them.
Students may wish to bring a thermos and/or lunch since there are no facilities for food
or drink at the Bainbridge training site.
CONDUCT:
Participants in the Truck Driver Training program are expected to behave in a
professional manner at all times. Misconduct includes the following and is subject to
disciplinary action: Dishonesty, disruption or obstruction of teaching, physical or verbal
abuse, theft, possession or use of alcohol or drugs, or failure to comply with directions
of College officials acting in the performance of their duties. Violation of any federal,
state, or local laws will be turned over to the appropriate agency.
I, read and understood the above information.
(Please Print)
Signature: Date: ______________________
click to sign
signature
click to edit
Division of Career and Community Education
107 Railroad Avenue / Elkton, MD 21921 / 410-287-1615 / Fax: 410-398-4429
STUDENT OBLIGATIONS
SCHEDULE
Full-time program: Weekend program:
Start Date: ______ Start Date______________
Hours: ______ Hours: ______
I understand that I will be required to study outside of class. I am willing and will be able to complete
homework assignments. Yes No
I understand that regular attendance is mandatory, and I must have 80% attendance to receive a
certificate. There are NO excused absences. Upon missing 56 hours in the full-time class, or 32 hours
in the part-time class, I will not be able to continue in the program and will forfeit any tuition and/or
fees paid. If I am funded through an agency and I am dropped for attendance issues, I also understand
that agency has the option to collect the tuition and fees paid to the college. Yes No
I will be able to attend to my personal business (such as routine dentist or doctor's appointments)
before class begins. Yes No If answer is "No", please state the reason: ______________
I will be able to attend class every day, except in the case of emergency. I will be on time and stay all
day. Yes No If answer is "No", please state the reason:
DOT PHYSICAL AND DRUG TEST
I have read the DOT physical requirement regulations. Yes No
I understand I will be required to take a DOT physical and drug test before enrollment, and I will be
subject to random drug and alcohol testing throughout the course. Yes No
Division of Career and Community Education
107 Railroad Avenue / Elkton, MD 21921 / 410-287-1615 / Fax: 410-398-4429
RANGE CONDITIONS
I understand that while on the range I will be required to be on my feet all day and climb in and out of
a conventional tractor repeatedly to take my turn during the exercises. Yes No
I understand I will be expected to withstand varying & sometimes unpleasant hot, cold, wet, and/or
windy weather conditions while working with instructors & other students on the range. Yes No
I am aware of the above items and will be able to fulfill my student obligations.
Name:
(Please Print)
Signature: Date:
CONSENT
This program is funded by the State of Maryland’s EARN Maryland Grant Program,
administered by the Maryland Department of Labor, Licensing and Regulation (DLLR). As a
recipient of EARN Maryland funds, this program is required by law to collect certain
demographic information from training participants and to provide such information to DLLR
for reporting purposes. Any demographic information provided to DLLR will not contain
personal identifiable information. By enrolling in this program, I grant permission to share my
demographic information with DLLR. This program reserves the right to modify this privacy
statement at any time. Substantial changes to this clause will be publicized to you and also
displayed as a prominent notice on our website. The conditions outlined in this letter have been
explained to me in an individual meeting and I understand and agree with these conditions.
______________________________________________ ___________________________
Signature Date
For internal use only:
Participant Identification Number: _________________________________________________
click to sign
signature
click to edit
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome