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1960510339857Commercial Truck DriverApplication & Checklist00Commercial Truck DriverApplication & Checklistleft10031600Continuing Education – Bldg A3345 Redwood HighwayGrants Pass, OR 97527Fax: 541-471-3549Thank you for your interest in the Rogue Community College Commercial Truck Driver Training Program! The Rogue Community College Commercial Truck Driver Training Program accepts students on a first-come first-served basis. Applications will be processed in the order they are received, and are subject to approval and availability. Documentation may be submitted via either fax, mail, or in person. Students should date their application to ensure it is processed accordingly. To apply to enroll in our Commercial Truck Driving program please submit the following items:Completed Registration FormCompleted Driving History Form Completed Employment History FormFront/Back copy of Driver License You will be notified via email regardless of whether your application was tentatively approved or denied. Upon tentative approval, you will be required to submit additional items to support your application. This will include the following:$250.00 Non-refundable Processing Fee (payable via check, cash, or debit/credit card)Signed Program Regulations packetSigned Responsibility of Payment packetSigned Release of Information formDMV 5-year Drive Record from all states you have held a license in within the last five (5) yearsCopy of DOT Medical Card (if available – must be current)These additional items will be required within two (2) weeks of tentative approval notification OR three (3) weeks prior to the first day of the course, whichever occurs first. If all required items have not been received by this deadline your application may be rejected and your seat given to the next student in line.Upon official approval of your application, you will be scheduled for a DOT drug screen and physical (unless DOT medical card has already been submitted). Please note that although the use of cannabis and cannabis-related products is legal in Oregon, this program is federally regulated and cannabis use will result in a drug test failure and exclude applicants from the program. The office of the Rogue Community College Continuing Education Department is located primarily on the Grants Pass campus. Arrangements to pick up or drop off an application to the White City campus may be made if scheduled in advance. 581456210721Date:____________00Date:____________left13729300147383510795Commercial Truck Driver RegistrationProvide full legal name as printed on your driver’s permit.00Commercial Truck Driver RegistrationProvide full legal name as printed on your driver’s permit.Continuing Education – Bldg A3345 Redwood HighwayGrants Pass, OR 97527Fax: 541-471-3549Providing your social security number is voluntary. If you provide it, the college will use your social security number for keeping records, doing research, reporting enrollment, aggregate reporting, extending credit and collecting debts, and providing required information related to the Taxpayer Relief Act of 1997 to IRS. Your social security number will not be given to the general public. If you choose not to provide your social security number, you will not be denied any rights as a student. Please read the statement in the policy section of the class schedule, which describes how your number will be used. Providing your social security number means that you consent to use of the number in the manner described. Social Security Number:Term and Session Requested:Student ID #______________________________________ _____________________________________ _____________________________Last Name (as printed on permit)First Name (as printed on permit)MIPrevious________________________________________________ ______________________________ ____________________________Mailing AddressCityStateZip CodeHome Phone #--Cell Phone--Email: ODL#Date of IssueFemale___ Male___ Date of Birth _______________ U.S. Citizen? ___yes ___no Country, if other than U.S. _________________________Will you have been a resident of Oregon 90 days prior to the start of the term? ___ yes ___ no If no, what state? ___________Veteran? ___ yes ___ no Vietnam era Veteran? ___ yes ___ noIs English your second language? ___ yes ___ noHigh SchoolState:Graduation Date:HS Completion Level:Ethnicity/Race:Reason for attending:Employment:Educational Goal:?GED?Hispanic or Latino?Explore career or educational options?Full-time?GED?External Diploma Program?American Indian or Alaska Native?Earn GED?Part-time?Certificate/2-year degree?Attendance completion?Asian?Improve writing, reading, or math skills?Retired?Just taking classes?High School Graduate?Black or African American?Job skills improvement?Unemployed?Transfer to 4 year school?Proficiency exam?Native Hawaiian/Other Pacific Islander?Learn English?Undecided?Did not complete High School?White?OtherMedical Needs:?Still in High School?Decline to Respond?Personal interest/enrichment?Yes?Other?Skills to get a job?No?Transfer to a 4-yr collegeIf yes, specify:??Data Release Statement: To ensure efficient service and effective communication, I authorize school officials from RCC to share information from my educational records for the purpose of admission, advising, registration, financial aid, and billing. I certify the information I have provided to RCC is true.Student SignatureDriving HistoryHave you had any previous truck driving experience?Yes _____ No _____If yes, explain:Have you had any driving accidents in the past five years? Yes _____ No _____If yes, explain:Have you had any moving violations in the past five years? Yes _____ No _____If yes, list how many, when, and the violation. Have you had any alcohol-related violations? Yes ______No _____If yes, list dates.Have you ever been convicted of a misdemeanor? Yes _____ No _____If yes, provide explanation and dates.Have you ever been convicted of a felony?Yes _____ No _____If yes, provide explanation and dates.Have you lost your driving privileges or had a restricted driver’s license in the past ten years? Yes ____ No_____If yes, list dates.Employment HistoryPlease give an accurate and complete full-time and part-time employment record. Do not substitute your resume. Start with your present or last employer. Explain all breaks in continuous employment. Be specific regarding experience related to the position for which you are anization/Company Name:AddressYour Title_Name of Supervisor/telephone:Describe duties (be specific)Employed from: month year to month yearNumber of hours per week monthly salary: startlastReason for leaving:May we contact this employer yes _____ no _____ Organization/Company Name:AddressYour Title_Name of Supervisor/telephone:Describe duties (be specific)Employed from: month year to month yearNumber of hours per week monthly salary: startlastReason for leaving:May we contact this employer yes _____ no _____ Organization/Company Name:AddressYour Title_Name of Supervisor/telephone:Describe duties (be specific)Employed from: month year to month yearNumber of hours per week monthly salary: startlastReason for leaving:May we contact this employer yes _____ no _____ ................
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