The Driving Academy of Northwest Arkansas

"This program (is) one of the best; mainly because of the reasearch and work done to develop an excellent and high-quality program."

Licensed by the Arkansas State Board of Private Career Education

Employment Interest Form (Pre—Application)

Instructions: This pre-application will be used as part of the certification process; therefore, it is important that you fill out all sections completely and accurately.

Last Name:

First Name:

Middle Initial:

Preferred name to be called by adults:

Date of birth:

Sex:
Male Female

Street Address:

City:

State:

ZIP:

Telephone (Home):

Telephone (Cell):

Telephone (Other):

E-mail Address:

Do you have daily internet access?
Yes No

In which position(s) are you interested? Receptionist Driving (BTW) Instructor Classroom Instructor

Desired average number of hours per week with Driving Academy of NWA:

Do you have driver education training?
Yes No

If so, what type and how many clock or credit hours?

Do you have previous driver instruction experience?
Yes No

If so, when and for whom?

Do you have at least seven hours of work experience directly related to driving and/or traffic laws (such as, but not limited to experience in law enforcement, investigating accidents, etc.)?
Yes No

If so, explain:

May we contact your present employer? Yes No

Present/Last Employer:

Job Title:

Years with this Employer:

Supervisor:

Supervisor's Title:

Supervisor's Telephone:

In the past two years, have you had a loss of consciousness or muscle control caused by any of the following conditions? If yes, check condition(s) and give date(s):

Brain or
head injury

Heart

Sleep
disorder

Seizure
disorder

Diabetes

Lung

Muscle
or nerve

Stroke

Other

Dates:

Do you possess a valid Arkansas driver license? Yes No

License #:

License Type:

Expiration:

Have you had your driver license suspended, canceled, revoked, or denied within the past thirty-six months? Yes No

Do you have more than eight point violations on your driving record? Yes No

Have you completed a recognized First Aid Class? Yes No

If yes, what year, and with whom?

If no, would you be willing to complete one? Yes No

Are you willing to train to be an instructor for Driving Academy of NWA? Yes No Not Applicable

Please give any information about yourself including previous training or work availability with primary job (days of week, hours, seasonal differences, varying shifts, on-call, etc.) that might help us with placement and/or scheduling.

By submitting this form, I certify that the information supplied by me in this pre-application is complete and true to the best of my knowledge and belief. I understand that my misstatement of material facts will cause forfeiture of all my rights to any employment or result in dismissal from employment, if hired, in the service of Driving Academy of NWA. I understand that my fingerprints and police record will be checked if I am employed. I authorize the release of any job-related information that Driving Academy of NWA may request from the above sources which may exist now or in the future.