Free 50519.FH11 - Indiana

PERSONAL HISTORY OF COMMERCIAL DRIVER TRAINING SCHOOL - OWNER OR MANAGER
State Form 50519 (R / 7-07)

INDIANA BUREAU OF MOTOR VEHICLES

The information in this document is confidential according to 140 IAC 4-1-1 thru 14. * Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is voluntary and you will not be penalized for refusal. INSTRUCTIONS: Please print or type OWNER OR MANAGER INFORMATION
Name of owner, partner, associate, corporate director, officer or manager (last, first, middle initial) Home address (number and street, city, state and ZIP code) Home telephone number E-mail address Weight Color of eyes Color of hair Date of application (month, day, year) Social Security number * Drivers license number Sex Date of birth (month, day, year)

(
Height

)

Name of nearest relative

Address of nearest relative (number and street, city, state and ZIP code)

Name of commercial driver training school (where you are an owner or manager) Address of school (number and street, city, state and ZIP code)

EDUCATION AND MILITARY SERVICE EDUCATION (check the highest grade completed)
GRADE SCHOOL 1 2 3 4 5 6 7 8 HIGH SCHOOL 9 10 11 12 OTHER 1 2 COLLEGE 1 2 3 4 5 6

Have you successfully completed a course in Driver Education at an accredited College or University? (if yes, complete the following)
Name of college or university Hours attended Date of completion (month, day, year) Name of instructor

Yes

No

MILITARY SERVICE Are you a veteran? (if yes, complete the following)
Date of service (month, day, year) From: To:

Yes
Branch of service

No
Type of discharge

EMPLOYMENT HISTORY List employment for the last 5 years
Name of employer Job title Name of employer Job title Name of employer Job title Name of employer Job title Name of employer Job title Address of employer (number and street, city, state and ZIP code) Date of employment (month, day, year) From: To: Reason for leaving

Address of employer (number and street, city, state and ZIP code) Date of employment (month, day, year) From: To: Reason for leaving

Address of employer (number and street, city, state and ZIP code) Date of employment (month, day, year) From: To: Reason for leaving

Address of employer (number and street, city, state and ZIP code) Date of employment (month, day, year) From: To: Reason for leaving

Address of employer (number and street, city, state and ZIP code) Date of employment (month, day, year) From: To: Reason for leaving

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QUESTIONS You must answer each of the following questions. All questions answered Yes must be explained in the area provided on this application. 1. Have you ever been known by any name other than the one shown on this application? 2. Have you ever been charged with, or convicted of, a felony? 3. Have you ever been charged with, or convicted of, manslaughter? 4. Have you ever been charged with, or convicted of, reckless homicide? 5. Have you ever been charged with, or convicted of, driving under the influence of intoxicating liquor? 6. Have you ever been charged with, or convicted of, driving under the influence of narcotics? 7. Have you ever been charged with, or convicted of, leaving the scene of a traffic accident involving death or personal injury? 8. Have you ever been charged with, or convicted of, perjury or making any false statements? 9. Have you ever been charged with, or convicted of, any traffic violation other than parking violations? 10. Have you ever been charged with, or convicted of, any crime involving immoral conduct? 11. Have you ever been charged with, or convicted of, any misdemeanor other than traffic violations? 12. Are you now involved with any investigations or court proceedings relating to the matters stated in questions 2, 3, 4, 5, 6, 7, 8, 9, 10, or 11? 13. Has your license to drive in Indiana or any other state ever been refused, cancelled, suspended, or revoked? 14. Has your commercial driving training school instructors license ever been denied, cancelled, suspended, or revoked? 15. Is there any motor vehicle accident judgments against you that have not been satisfied? 16. Have you given driver training instruction for compensation within the past twelve (12) months?
Explanation of all the previous questions answered Yes

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No

Yes Yes Yes Yes

No No No No

AFFIDAVIT OF APPLICANT The applicant understands and agrees that: 1. If he/she terminates employment with the commercial driver training school listed herein he/she will surrender his/her license to instruct at said school, 2. If he/she becomes employed by another commercial driving training school, he/she will make application for a new instructors license for said school. The undersigned affirms that he/she has read the entire foregoing application; that he/she knows the contents thereof; and that all answers, statements and all other matters contained therein are true in substance and in fact, and that the undersigned is of high moral character and reputation and has not been adjudicated a felon the ten (10) years immediately preceding the date of application.
Signature of applicant Printed name of applicant Date signed (month, day, year)

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