Driving Beyond Barriers Application

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Gender *

Female

Male

Marital Status *

Single

Married

Separated

Divorced

Widow

Are you or members of your family current or past participants in any Mind the G.A.P.P. programs or services? *

Yes

No

Have you ever pled guilty, no contest to, or been convicted of a misdemeanor or felony? *

Yes

No

Employment Status *

Full-Time

Part-Time

Self-Employed

Not Employed

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Completion Date

MM

DD

YYYY

Are you currently a student? *

Yes

No

Have you had a valid driver’s license for the past two years? *

Yes

No

Do you currently have a valid Class A permit? *

Yes

No

Date of Class A Permit Expiration

MM

DD

YYYY

I am seeking a: *

Class A Permit

Class A Commercial Driver's License

Have you had a DUI or any speeding tickets in the past three years? *

Yes

No

Are you over 21 years old? *

Yes

No

Have you had any felonies in the past 3 years? *

Yes

No

Can you read, write, and speak English? *

Yes

No

Can you lift 50 lbs. and work outside in a variety of conditions? *

Yes

No

Are you a U.S. Citizen or have a Right to Work? *

Yes

No

Are you registered for the Selective Service? *

Yes

No

Are there any medical and/or physical concerns to be considered in your participation? *

Yes

No

Are you a Veteran? *

Yes

No

Prefer Not to Answer

*

Yes

No

Phone *

(###)

###

####

Phone *

(###)

###

####