Pre-Enrollment Questionnaire

SSN - This will be collected from you by the enrollment councelor.

Home Address

City

State

Zip Code
(ex. 97015 )

Phone/Mobile
(ex. 503-123-4567 )

Birthdate
(ex. 010203 - MM DD YY )

Age

License Number
(State issued driver license ID)

Issue Date
(ex. 010203 - MM DD YY )

State of Issue
(ex. OR)

Please answer the following questions and select YES or NO to questions 2-13. If required, please explain your answers in the space provided.

01) How many moving violations (Tickets) have you been convicted of in the last 5 years?
None At Least One or More Enter NONE, or, if At Least One or More, give the number, and explain:

02) Have you been involved in ANY At-Fault accidents in the last 5 years?
No Yes If yes, explain:

03) Have you ever been convicted of any major traffic violations? (reckless, eluding, speed racing, negligent, carless, etc.)
No Yes If yes, explain:

04) Have you ever had a driving or NON driving Alcohol related violation? (Of any kind)
No Yes If yes, you must explain:

05) Has your driver's license been suspended or revoked in the last 5 years?
No Yes If yes, explain:

06) Have you ever been convicted of a felony?
No Yes If yes, include details such as: when, what for, were you incarcerated. If you spent time in jail, how long? - (give start and end dates)

07) Have you ever been convicted of a Misdemeanor?
No Yes If yes, when, and explain?

08) Do you have any difficulties reading, writing, or understanding English?
No Yes If yes, you must explain:

09) You must pass a DOT physical. Do you currently have or have you ever had any physical limitations and/or do you have any vision or hearing problems in either eye or ear? Do you have diabetes, epilepsy, seizures, high blood pressure, heart problems, mental illness, etc.? Do you have lifting limitations under 80 lbs?
No Yes If yes to any of the above, explain:

10) Is driving a vehicle with a clutch new to you? (You must know how)(If you are not experienced using a clutch, we will explain a possible option for you.
No Yes If yes, meaning you think it will be a problem, explain:

11) You may need to verify your 10 year work history. Will this be a problem?
No Yes If Yes, explain:

12) DMV/DOT requires you provide a birth certificate or passport. Can you do so?
No Yes If No, you can't provide the documents, explain:

13) Are you a U.S. Citizen or permanent legal resident of the U.S.?
No Yes If No, explain:

14) What is your educational background? (You will be required to provide proof)

Education History

If you did not finish High School, or have one of the above (these are not required to attend) what was the last grade completed?

College Experience

15) What source of advertisement brought you to IITR?

Use this box to define Other or specify Agency Councelor, Newspaper,
Trucking Company, Former Student, Phone Book or TV Station.

16) What is your previous employment experience? (what kind of work have you done)

17) What type of employment would you like if you attend and graduate?

18) If I attend, I plan to pay my tuition by the method selected below:

Additional Explanation:

19) If applying for an IITR Internal Student loan: My Credit is:

If you have poor credit, can you obtain a cosigner? No Yes

20) Mandatory questions required by our Licensing Agencies

Race:

If other, please fill in below:

Gender:
Male Female

Acknowledgements: -
By Submitting this form you CLEARLY UNDERSTAND: IF I ANSWERED YES TO ANY OF THE QUESTIONS 1-10 ON THIS FORM, I MAY STILL ATTEND BUT IT MAY PROHIBIT ME FROM OBTAINING EMPLOYMENT AS A TRUCK DRIVER AND I MAY BE REQUIRED TO SIGN A PLACEMENT WAIVER. FUTHERMORE: I HEREBY CERTIFY THAT BY SUBMITTING THE FORM, THAT THE SUBMISSION ACTS AS MY SIGNATURE THAT ALL ENTRIES ON THIS FORM ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
YOU MUST TAKE AND PASS A DRUG SCREEN. DO NOT ENROLL IF YOU THINK OR SUSPECT THIS MAY BE A PROBLEM. Please type your initials and the phrase: I UNDERSTAND in the comment area as an indicator that you acknowledge this.
Comment

Final Email Verification -
Please re-enter your Email Address

Completing our pre-enrollment questionnaire does NOT obligate you to attend. Once completed, you will receive a confirmation page with links to a free IITR School Catalog for download and later review.

Pre-Enrollment Questionnaire