01
.
Untitled Page
02
.
PERSONAL INFORMATION
03
.
DEMOGRAPHIC INFORMATION
04
.
EDUCATION
05
.
EMPLOYMENT HISTORY (1)
06
.
EMPLOYMENT HISTORY (2)
07
.
EMPLOYMENT HISTORY (3)
08
.
REFERENCES
09
.
QUESTIONS
Commercial Driver’s License Class A Training Scholarship Application
For Native American Tribal Members/Descendants
APPLICATION DEADLINE – July 1, 2023
Late applications will not be accepted.
Fox Valley Technical Appleton, Wi
• ELDT Theory Course – Online – Must be completed before July 31, 2023
• Registration June 1, 2023
• Training: –In person Fox Valley- Travel comp’d starts July 01, 2023
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
First / Last name
Address
Email address
Date of Birth:
MM
/
DD
/
YYYY
Tribal Affiliation:
Do you have a valid driver’s license?
Yes
No
Driver’s License Number:
Have you had more than 3 moving violations in the last 5 years?
Yes
No
Have you been convicted of an OWI/DUI within the last seven years?
Yes
No
Are you a TrANS graduate?
Yes
No
When did you graduate?
Do you currently have a CDL Class A permit?
Yes
No
If yes, specify:
CDL requirement is to obtain a DOT drug test and physical before obtaining a permit. Are you willing to complete this before training? *Please see handout regarding the DOT physical about disqualifications.
Yes
No
Do you have your own vehicle?
Yes
No
If not, how will you get to the CDL training?
CDL training will require about 4 weeks of dedication. Are you able to attend for the length of time needed?
Yes
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
The following information is voluntary. All information is protected under the Privacy Act of 1974 which states that we must explain why we are asking for information and how it will be used. The Tribal Labor Advisory Committee uses this information for reporting to its funding source. This information does not determine or affect your eligibility for this training scholarship. This data may be used for referring to additional resources, further training, and work placements.
Are you a veteran?
Yes
No
Are you currently employed?
Yes
No
Do you have a work-related disability?
Yes
No
Are you currently living in a shelter?
Yes
No
Have you ever been convicted of a felony?
Yes
No
Are you currently on probation or parole?
Yes
No
Gender
Female
Male
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Check any applicable options:
No High School Diploma or GED
GED/HSED
High School Diploma
Associates Degree
Some College Bachelor’s Degree or Higher
Certifications or additional training you have had:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
EMPLOYMENT HISTORY (1)
Employer Name:
Employer Address
Phone:
Start Date:
MM
/
DD
/
YYYY
End Date:
MM
/
DD
/
YYYY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Employer Name:
Employer Address:
Employer Phone number:
Start Date
MM
/
DD
/
YYYY
End Date
MM
/
DD
/
YYYY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Employer Name:
Employer Address:
Phone number
Start Date
MM
/
DD
/
YYYY
End Date
MM
/
DD
/
YYYY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
REFERENCES
1)
Name:
Company:
Job Title:
Email address
Phone number
Years Known:
2)
First / Last name
Company:
Job Title:
Email address
Phone number
Years Known:
3)
First / Last name
Company:
Job Title:
Email address
Phone number
Years Known:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Please answer the following questions.
Why do you want this training?
What do you plan to do after the training is completed and you obtained your CDL Class A license?
SIGNATURE: I certify the answers provided on this application are true and correct with consequential omissions of any kind. I understand any misleading or incorrect statements may render this application void, and if selected for the training scholarship, may be cause for revocation. I authorize the companies, schools, and persons named above to give any information requested regarding my employment, character, and qualifications. I hereby release said companies, schools, or persons from any liability for any damage issuing this information in consideration of selection for the TrANS program. I authorize the Tribal Labor Advisory Committee to contact previous employers and references given here and release them from all liability. I understand that completion of this application is no guarantee of acceptance to training.
Signature
Clear
Date
MM
/
DD
/
YYYY
Verification
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20