Please Fill Out Application and send to Info@westwindcdl.com or mail to

 ATTN: Mardy L. Leathers c/o Westwind CDL Training Center

PO Box 86 Cuba, MO 65453

   Post Office Box #86 Cuba, Missouri 65453       888.330.7410    573.885.1059 Fax     www.westwindcdl.com

                                  ENROLLMENT APPLICATION

 Last Name:                                                                    First Name:                                        

Mailing Address:                                                            City/State/Zip:                                    

Day Phone:                                            Evening Phone:                                                           

SSN:                                                    Driver’s License #:                                                      

State:                             Birthdate:                                               

HOW DO YOU INTEND TO FINANCE YOUR TUITION? (CHECK ONE):

¨     Cash or Cashiers Check

¨     Credit Card – Westwind CDL Training Center Accepts Visa or MasterCard Only

¨     Being sponsored by an agency? Agency Name:                                                            

Have you been convicted of more than 3 moving traffic violations in the last 3 years?           Yes         No

Is your driver’s license currently expired, suspended, invalid, or w/out picture?                      Yes         No

Do you have any outstanding or unpaid traffic fines or citations in any state?                        Yes         No         

Has your driver’s license been suspended or revoked w/in the last 5 years?                            Yes         No

Have you ever been convicted of any alcohol related traffic violation?                                     Yes         No

Have you ever been convicted of use, sale or possession of an illegal drug?                           Yes         No

Are you able to climb and work up to 15 feet above ground?                                                       Yes         No

Are you able to climb into and out of an over-the-road tractor, 4 to 6 feet,

8 to 10 times per day?                                                                                                                           Yes         No

Are you at least 18 years of age?                                                                                                       Yes         No

Are you able to pass and maintain a DOT Physical?                                                                      Yes         No

Please explain any yes answers to any of the first 6 questions:                                                                              

Previous or Present Employer:                                                                                                  

Address:                                                                                                                                  

Date of Employment: From (Month/Year)                                  to (Month/Year)                     

Position Held:                            Reason for Leaving:                                                                 

May we contact this employer for reference purposes?                  Yes                         No 

Previous or Present Employer:                                                                                                 

Address:                                                                                                                                  

Date of Employment: From (Month/Year)                                  to (Month/Year)                     

Position Held:                            Reason for Leaving:                                                                 

May we contact this employer for reference purposes?                  Yes                         No

Previous or Present Employer:                                                                                                 

Address:                                                                                                                                  

Date of Employment: From (Month/Year)                                  to (Month/Year)                     

Position Held:                            Reason for Leaving:                                                                 

May we contact this employer for reference purposes?                  Yes                         No

Previous or Present Employer:                                                                                                  

Address:                                                                                                                                  

Date of Employment: From (Month/Year)                                  to (Month/Year)                     

Position Held:                            Reason for Leaving:                                                                 

May we contact this employer for reference purposes?                  Yes                         No

Please list all other states you’ve held a driver’s license in the last 3 years not listed:

State:                License #:                                State:               License #:                               

Please list all traffic violations in the last 5 years (excluding parking):

Violation:                                   Date:                     Violation:                            Date:               

Violation:                                   Date:                     Violation:                            Date:               

Violation:                                   Date:                     Violation:                            Date:               

I, the undersigned have submitted this information as being true and accurate, realizing that approval

or disapproval of my enrollment will be based on this form and that any misrepresentation or omission

of information called for is cause for rejection.  Further, I clearly understand that school acceptance

of my enrollment will be based on this form and the information contained herein.  In addition, I hereby authorize the school to investigate the information submitted on this form and to contact individuals, states in regard to driver’s licenses, credit bureau agencies, or other parties listed on or related to either side of this application. 

Applicant Signature:                                                                   Date: