Apply Online

How did you hear about us?*

Please answer the following Questions honestly

1. Are you at least 21 years of age?  Yes No

2. Have you held a regular drivers license for at least one year?  Yes No

3. Do you have a valid Michigan Drivers License?  Yes No

4. Do you have a high school diploma or GED equivalent?  Yes No

5. Have you ever driven a manual (stick shift) transmission?  Yes No

6. How many jobs have you held in the last five years?

7. How many moving violations do you have in the last 3 years?

8. How many accidents have you been involved in the last 10 years?

9. Are you currently?  Employed Unemployed

10. Are you a military veteran?  Yes No

11. Do you have access to your Birth Certificate?  Yes No

If you answer YES to questions 12-28 please explain below

12. Have you been fired from your job?  Yes No

13. Have you been unemployed for a period greater than 6 months?  Yes No

14. Have you ever been convicted of a felony?  Yes No

15. Have you ever been convicted of a misdemeanor?  Yes No

16. Have you ever been or are you currently on parole or probation?  Yes No

17. Have you ever had your license suspended?  Yes No

18. Have you ever been convicted of careless or reckless driving?  Yes No

19. Have you ever been convicted of a DUI, OUIL, MIP, etc.?  Yes No

20. Have you ever had a positive drug or alcohol screen?  Yes No

21. Are you an insulin injection dependent diabetic?  Yes No

22. Do you have Epilepsy?  Yes No

23. Do you have high blood pressure?  Yes No

24. Do you have any vision problems?  Yes No

25. Do you have a lifting restriction?  Yes No

26. Do you have a sleep disorder? (Sleep Apnea)  Yes No

27. Are you currently under a Doctors care?  Yes No

28. Are you currently taking prescription drugs?  Yes No

If you answered yes to questions 10-28 please explain below and list dates if applicable?

Type your name and date below if you agree your answers are factual to the best of your
knowledge.