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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.

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:
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



Date Type of Vehicle Nature of Accident Preventable Fatalities Injuries Damage


Are there any restrictions on your license? If "yes", explain:
Have you ever been:
A. Convicted of an alcohol/drug related driving offense?
B. Convicted for possession, sale, or use of a narcotic drug, amphetamine, or other controlled substance?
C. Arrested or convicted of any crime or are any charges pending?
D. Convicted of a felony?
E. Denied a license, permit or privilege to operate a motor vehicle?
F. Have any license, permit, or privilege been suspended or revoked in any state?
G. 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?
H. 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?
If the answer was "Yes" to any of the above questions, list State, circumstance, and date:
Select the highest grade completed (Elementary through Highschool): College:
Are you a citizen of the United States?
If no, explain:
Have you served in the Armed Forces within the past ten (10) years? Dates: From:
 To:
If Yes, you'll also need to submit a DD214
Past Employment References
You must show a minimum of three (3) years verifiable employment. Show unemployed time also. Use additional paper, if necessary. Note: Some companies may require 10 years employment. If accepted, be prepared to list additional employment history.
Current Employer Name:
Address: City:: State: Zip Code:
Position Held: Employment dates (mo/yr):
to
Reason for leaving: Contact Person: Phone:
Last Employer Name:
Address: City:: State: Zip Code:
Position Held: Employment dates (mo/yr):
to
Reason for leaving: Contact Person: Phone:
Second Last Employer Name:
Address: City:: State: Zip Code:
Position Held: Employment dates (mo/yr):
to
Reason for leaving: Contact Person: Phone:
Third Last Employer Name:
Address: City:: State: Zip Code:
Position Held: Employment dates (mo/yr):
to
Reason for leaving: Contact Person: Phone:
(Use additional paper for employer information if needed)
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: