2379 Smokey Park Hwy

Candler, NC 28715
Phone: (888) 878-9986
Fax: (828) 348-1949

CDL TRAINING ENROLLMENT APPLICATION

CDL Training Admission Requirements
o Must be 18 years of age or older

o Hold a valid driver's license within the U.S.

o Have a valid DOT Medical Examiners Certificate

o Must obtain an MVR confirming validity of current Driver's License

o Must be able to take and pass a DOT urine drug test (this is done prior training start date)

o Understand highway traffic signals and signs

o Have basic fundamental skills to read, write and speak English, as per Federal Motor Carrier Safety
Regulations.(391 FMCSR)

Please select the type of Training you are applying for: Class A Training Class B Training

Do you have a job lined up? If so, with whom? No

PERSONAL INFORMATION

Please read and complete all sections to the best of your ability.

Student Information
ALHAJ AHMED ABDALLAH MOHAMMED
First Name Last Name Middle Name Suffix

4082 01/01/1986
Last 4 digits of SSN Date of Birth mm/dd/yyyy Male Female

Personal Contact Information

7163929723 alhajahmed1117@gmail.com
Cell Phone Email Address

Emergency Contact Information

Ibrahim Mohamed A friend +1 (423) 314-1155
Name Relationship to you Cell Phone 000-000-0000

Home Address
3700 Cherryton Dr Chattanooga TN 37411
Current Street Address City State Zip Code

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 2379 Smokey Park Hwy
Candler, NC 28715
Phone: (888) 878-9986
Fax: (828) 348-1949

DRIVERS LICENSE INFORMATION

Drivers License Number 142714043 Expiration Date 11/21/2027

State Issued TN

Do you currently posses a Commercial Learner's Permit? If yes, please provide us with the following info:

Class A Expiration Date 06/18/2022 Restrictions/Disqualifications None

Is your license currently suspended or revoked?

Yes No

MEDICAL CERTIFICATE INFORMATION

DOT Medical Certificate

Certification Date 06/17/2021 Expiration Date 06/17/2023

Do you take any medication that might affect your ability to safely operate a commercial motor vehicle?

Yes No

3$<0(170(7+2'

We accept checks, money orders and credit card payments. If paying by check or money
order, please make them payable to Carolina CDL Training Center, Inc.

Do you need assistance with funding opportunities? Yes No

Are you interested in participating in job placement program? Yes No

APPLICANT NOTICE
By submitting this application, I certify that all the information on this form is correct and
complete to the best of my knowledge. I authorize Carolina CDL Training Center, Inc, or their agents
to obtain Motor Vehicle Reports in accordance with state and federal laws. I understand that false
or misleading information will disqualify me from further consideration and I am subject to
immediate termination if this becomes known after enrollment. I authorize my previous employers to release
any information required by Carolina CDL Training Center, Inc and hold them harmless of all liability for the
release of said information.

Signature: Alhaj Mohammed (Jun 28, 2021 14:05 EDT)

Email: alhajahmed1117@gmail.com

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