All fields must be completed, or your application will not be processed! Applications will be kept on file for one (1) year. After one (1) year, applicants must reapply for training.
Date:
1. Name (Last, First, MI) :
2. Address: State: Zip-
3. Cell Ph#: - - Home Ph#: - -
4. Emergency Contact Name:
Relationship: Contact Ph #: - -
5. Birthdate: Sex: Male Female
6. Driver's License #: Class:
7. Endorsements:
8. Expiration dates of your Drivers License:
Expiration dates of your Learners Permit:
9. Years of truck driving experience:
10. Medical Examiner's Certificate Examination Date:
11. I am a member of Local: Out of Work Eligibility List: A B C
12: Most recent Employer:
13. Do you want/need hazardous waste worker training? YES NO
14. Do you need Class "A" License Training? YES NO
15. Training desired (you must have a Class "A" or B License to qualify or these courses):
16. Are you taking any kind of medicaiton? YES NO
If YES, what type (please name):
Do you have any medical or medicinal condition which would prevent you from safely operating
machinery?: YES NO
If YES, please explain:
17. Are you currently receiving any of the following?: Unemployment Insurance Benefits
Workman's Comp. State Disability Insurance Private Disability Other
18. You must submit copies of the following documents to Lisa Beauchamp at Local 150 so they can be matched up with your application and be forwarded to the Training Center:
Driver's License
Medical Examiner's Certificate (Green D.O.T. Card)
DMV Printout (Must be issued within 30 days of application)
Class "A" Lerners Permit (if applying for Class "A" License Training)
Union Dues Receipt (must be current for month of application)
19. This application must be signed by the Union, Employer Representative, or Funding Agency and the completed application must be sent to: NCTAT, Attn: Shelly Hinkle, P.O. Box 1404, Rancho Murieta, CA 95683
Lisa Beauchamp will do this for you once she receives the necessary documents. You may email them to Lisa at lbeauchamp@teamsters150.org, fax them to 916-392-7675, or hand deliver or US Mail them to Local 150, 7120 East Parkway, Sacramento, Ca 95823
I CERTIFY THAT ALL STATEMENTS MADE ON THIS FORM ARE TRUE AND CORRECT. IUNDERSTAND THAT AS A CONDITION OF RECEIVING TRAINING FROM THE NCTAT, I WILL BE REQUIRED TO SUBMIT A DRUG AND/OR ALCOHOL TEST. (A COPY OF THE NCTAT DRUG FREE AWARENESS POLICY IS POSTED AT THE TRAINING CENTER AND IS AVAILABLE UPON REQUEST). I FURTHER UNDERSTAND THAT THERE ARE INHERENT RISKS TO CONSTRUCTION AND CONSTRUCTION TRAINING AND I AGREE TO HOLD THE NCTAT HARMLESS FOR ANY ILLNESS OR INJURY WHICH MAY OCCUR DURING TRAINING.
