Central Tech

Application for Admission:

Download Application as PDF if mailing application.

Central Tech in compliance with Title VI of the Civil Rights Act of 1964, Title VII and Title IX of the Educational Amendments of 1974, Section 504 of the Rehabilitation Act and the American Disabilities Act (ADA), does not discriminate on the basis of race, color, religious creed, national origin, age, gender, or disability or veteran status in any of its policies, practices, or procedures. These equal opportunity provisions include, but are not limited to, admissions, employment, financial aids, and educational services.

TDTAdmissions@centraltech.edu

Last Name:	First Name:	Middle Initial:

Date of Birth (MM/DD/YYYY):	Home Phone:	Alternate Phone:

Present Mailing Address:	City::	State:	Zip Code:

Licensing State:	Class (A, B, C, or D):	Expiration Date:

Email Address:


Traffic Convictions/Forfeitures: List all motor vehicle convictions and forfeitures for the past five years
Date:	Location (State)	Charge	Penalty

Date:	Location (State)	Charge	Penalty


Accident Record: List all accidents with motor vehicles for the past ten (10) years, include preventable and non-preventable.
Date	Type of Vehicle	Nature of Accident	Preventable	Fatalities	Injuries	Damage
			Yes	Yes	Yes
			No	No	No
Date	Type of Vehicle	Nature of Accident	Preventable	Fatalities	Injuries	Damage
			Yes	Yes	Yes
			No	No	No


Are there any restrictions on your license?	Yes No	If "yes", explain:

Have you ever been:

Convicted of an alcohol/drug related driving offense?

Yes No

Convicted for possession, sale, or use of a narcotic drug, amphetamine, or other controlled substance?

Yes No

Arrested or convicted of any crime or are any charges pending?

Yes No

Convicted of a felony?

Yes No

Denied a license, permit or privilege to operate a motor vehicle?

Yes No

Have any license, permit, or privilege been suspended or revoked in any state?

Yes No

During the past (2) two years, have you tested positive on a pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by the Department of Transportation (DOT) drug and alcohol testing rules?

Yes No

During the past (2) two years, have you refused to test on a pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by the Department of Transportation (DOT) drug and alcohol testing rules?

Yes No

If the answer was "Yes" to any of the above questions, list State, circumstance, and date:

Are you a citizen of the United States?

Yes
No

If no, explain:

Have you served in the Armed Forces within the past ten (10) years?	Yes No	Dates:	From:	To:
If Yes, you'll also need to submit a DD214

The facts set forth in this application are true and complete. I have read and do understand the entrance requirements as outlined by Central Tech. It is understood that information requested by a potential employer is given with my permission. I understand that if accepted, false statements on any part of this application shall be considered sufficient cause for dismissal.

Agree Disagree

Date: