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CDL Instructor Qualification Form

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Instructor Information

Date +

Instructor Name

Phone Number

Work Email Address

Personal Email Address

Employer Name

Position/Title

Date of Hire +

Length of Service

Employment Status

Percent of Time Spent Instructing

Estimated percentage of time you will contribute to each category per employee in an 8 week period. Should total 100%

Classroom/Lab %

Range BTW %

Street BTW %

Current Job Duties: (i.e. driver, supervisor, mentor)

0/500 characters

Licenses

CDL

KS Lic Number

State/Prov

Date Issued +

Expires +

Class

Required to have an Medical DOT Card

Endorsements

H - Hazardous Materials

N - Tank Vehicle

P - Passenger Transport

S - School Bus

T - Double/Triples

X - Tanker/Hazmat

Vocational Licenses or Certifications Currently Held

Issued by and Date of Issuance

+-

Is a Teaching License or Certificate Required?

Yes

No

Is Driver Qualification File per Part 391 of the Federal Motor Carrier Safety Regulations Complete and up to date?

Yes

No

Road Test

# Years Tractor-Trailer Truck Driving Experience

# Years Truck Driving Experience Other than Tractor-Trailer

# Years High School, College, or Vocational Teaching Experience

# Years Other Significant Teaching/Training Experience

# Years as a Driver-Trainer

List work experience related to tractor-trailer truck driving, teaching and supervision, and driver-trainer.

Start with present position and work backwards.

Company

Job Title

Dates

Total Years

Position

Add Additional

Yes

Company

Job Title

Dates

Total Years

Position

Add Additional

Yes

Company

Job Title

Dates

Total Years

Position

Add Additional

Yes

Company

Job Title

Dates

Total Years

Position

Add Additional

Yes

Company

Job Title

Dates

Total Years

Position

Please submit the following items:

Drivers License (Front & Back)

DOT Medical Card

Road Test

Motor Vehicle Record (Current)

Driver Certification (record of violations)