CLIENT INFO SHEET

(MEMBERS ONLY)

Applicant Information

Name:     __________________________________________________________

Date of birth:  __________________________________________________________ 

DL#:    __________________________________________________________

Phone: __________________________________________________________    

Current address:     __________________________________________________________

City:__________________________________________________________

State:__________________________________________________________

ZIP Code:__________________________________________________________

Full CLASS B CDL w/AIRBRAKE AND PASSENGER ENDORSEMENT

Payment:  $0

E-mail:__________________________________________________________

Employment Information

Currently unemployed:  Yes                              No

Current employer:__________________________________________________________

Employer address:__________________________________________________________

How long?__________________________________________________________

Phone:__________________________________________________________

Fax::__________________________________________________________

City::__________________________________________________________

State:__________________________________________________________:

ZIP Code::__________________________________________________________

Position::__________________________________________________________

Hourly      Salary      (Please circle)

Annual income::__________________________________________________________

​

Emergency Contact

Name of a relative not residing with  you:_________________________

Address:__________________________________________________________

Phone:_______________________________________________________

City:__________________________________________________________

State:_________________________________________________________

ZIP Code:_____________________________________________________

Relationship:__________________________________________________

Hardship Essay (not less than 250 words, nor more than 500 please)

 (MORE SPACE  NEEDED? ADD ATTACHMENT)

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

​

References  (TWO)

Name:       _________________________________________

Address:   _________________________________________

Phone:      _________________________________________

Best contact time:  _______________

Click here for Terms and Conditions 

I authorize the submission of this form to BNTR for my entry into the 2018 CDL contest.  I have read the Terms and conditions and agree to comply with the drawing rules.

Signature of contestant:  ______________________________

Todays Date:  ___________