JDRCC CDL Truck Driving Program Fill out the following forms to complete your application to the JDRCC CDL Truck Driving Program. Name* First Last Address* Street Address Address Line 2 City State ZIP / Postal Code Phone*Email* Are you 21 years of age or older?* Yes No Birth Date* MM slash DD slash YYYY Do you have any physical limitations or health problems such as those below, or any others that may disqualify you from obtaining a CDL license? If so, please explain:** Physical requirements: PLEASE REVIEW THE SHEET “Department of Transportation Physical Requirements”. No impairments to any limbs that affect safe driving. Diabetes (must not be on insulin), Epilepsy, Blood pressure (no higher than 140/90 max), Eyesight (correctable to 20/40, each eye), Hearing (forced whisper @ 5 ft.), differentiate red, green and yellow, no history of or clinical diagnosis of drug or alcohol use.DOT physicals and drug screens are mandatory for enrollment. If you have any questions as to your eligibility based on your physical condition or medications call WVDOT at (304)347-5935A $100.00 non-refundable deposit must be paid by all students prior to enrollment. In addition to the application fee, all of the following must be turned in to the main office prior to placement on the enrollment list, and/or the start of class Interview with Instructor*Physical**Drug ScreenDMV CheckCopy of SS Card and Drivers LicenseCompleted ApplicationFinancial ArrangementsAccident Insurance (Available through school if needed)Please collect all data and turn in to JDRCC CDL Program Office as follows: Items 1-8WIA PaperworkNOTE: It is highly encouraged that you pick up a CDL manual from JDRCC prior to start of class. If you are self funded, you can apply for the permit prior to the start of class but no more than 3 months since a permit is good for 6 months.I hereby give "John D. Rockefeller Career Center" my permission to verify any information stated above, and that the above information is true and valid to the best of my knowledge.* First Last Date* MM slash DD slash YYYY Please let us know how you heard about our program:Newspaper AdSchool MarqueeReferred by Trucking CompanyBooth at Trade Show/MallInternetFriend/RelativeSeen Our Trucks on the RoadOtherCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.