::TUTS:: » Qualifier Form

Pre-Enrollment Qualifier

General Information

Last Name*	First Name*	Middle Initial
Date of Birth (mm/dd/yyyy)*	Phone Number*	Mailing Address*
City*	State*	Zip*

Enrollment Information

Course Type	How soon would you like to start?*
Method of Payment	If agency, please provide name and city

Enrollment Qualification

Is your driver's license currently expired or suspended?		Yes No
Have you had more than 3 moving violations in the last 5 years?		Yes No
Has your license ever have been suspended or revoked?		Yes No
Have you ever been convicted of DWI?		Yes No
Have you ever been convicted of a felony Y/N Are you on parole?		Yes No
Do you have difficulty reading or writing English?		Yes No
Any history of Epilepsy, Diabetes or High Blood Pressure?		Yes No
Any Heart or Cardiac problems?		Yes No
Any Major Surgery, Knee or Back or Other Limitations?		Yes No
Any history of Mental illness?		Yes No
Any illegal drug use in the last 6 months?		Yes No
Any reason you would not pass a drug screening?		Yes No
Do you have any history of Dyslexia?		Yes No
Do you have any experience driving/shifting manual transmission vehicles?		Yes No
Any vision problems (worse than 20/40)?		Yes No