NMCC Commercial Driving Academy

Student information

Last Name:

First Name:

M.I.:

Social Sec. #:

Date of Birth:

Gender: M F

Mailing Address:

City:

State:

Zip:

County:

Country:

Phone #:

Secondary Phone #:

Email Address:

Drivers License Number:

State Issued:

Expiration:

Are you a U.S. Citizen: Y N

If you answer yes to any of the following, please explain on space provided
Have you had a moving violation in the past ten years?	Y N
Have you ever been convicted, or adjudicated of a felony?	Y N
If yes to any, details :

Preferred to start training on
August 26, 2024 Class B Upgrade to Class A
November 18, 2024 Day @ Presque Isle
November 18, 2024 Evening @ Presque Isle

Emergency Contact Information

Name:	Phone #:
Cell Phone #:	Work Phone #:

Education

I have a (n): Please check one:
High School Diploma Adult Education Diploma HiSET/GED

Name of School/ Testing Center:

Date of Graduation/Diploma Issued:
City: State:

Have you previously attended Northern Maine Community College? (NMCC, NMTC or NMVTI):
Yes No Year:

Let us know how you learned about NMCC - Commercial Driving Academy Program (please check all that apply)

Website Friend/Relative NMCC Alumni Employer TV Radio Newspaper Other

What attracted you to the Commercial Driving Academy Program?

Cost Size Close to home Program of Study Employment opportunities Other

Employment History - Please list three most recent employers

Most recent employer: Dates employed: to
Position: Duties:
Contact person for reference: OK to call for a reference? Y N
Was your job with this company designated as a safety sensitive function subject to drug and alcohol testing requirements for the department of transportation's (DOT) rule, 49 CFR part 40? Y N

Employer: Dates employed: to
Position: Duties:
Contact person for reference: OK to call for a reference? Y N
Was your job with this company designated as a safety sensitive function subject to drug and alcohol testing requirements for the department of transportation's (DOT) rule, 49 CFR part 40? Y N

I hereby consent I do not consent
to the use by Northern Maine Community College to use a photograph of me in any publications, website, advertisement, report or other material promoting the College or the system. I hereby waive any and all rights to inspect or approve such photograph(s), and I release the College and the MCCS for any and all claims arising from use of the photograph(s).

By Clicking the `Apply Now` button below I certify that all information on this application is accurate and complete.

The application process is complete for Commercial Driving Academy Program when the following are received:

Completed application form
Applicable high school transcripts or HiSET/GED diploma
Copy of valid Maine Driver's License
Copy of current driving record
Pre-entrance alcohol and controlled substance screen (found to be qualified)
DOT physical in accordance with the Federal Motor Carrier Safety regulations
Immunization record verifying vaccination (or titer results indicating immunity) for MMR (Measles, Mumps, Rubella) as well as Diphtheria/Tetanus vaccination administered within past 10 years.

Non-Discrimination Policy

Northern Maine Community College is an equal opportunity/affirmative action institution and employer. For more information, please call (207) 768-2791