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    Please answer the following Questions honestly

    1. Are you at least 21 years of age? YesNo

    2. Have you held a regular drivers license for at least one year? YesNo

    3. Do you have a valid Michigan Drivers License? YesNo

    4. Do you have a high school diploma or GED equivalent? YesNo

    5. Have you ever driven a manual (stick shift) transmission? YesNo

    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? EmployedUnemployed

    10. Are you a military veteran? YesNo

    11. Do you have access to your Birth Certificate? YesNo

    If you answer YES to questions 12-29 please explain below

    12. Have you been fired from your job? YesNo

    13. Have you been unemployed for a period greater than 6 months? YesNo

    14. Have you ever been convicted of a felony? YesNo

    15. Have you ever been convicted of a misdemeanor? YesNo

    16. Have you ever been or are you currently on parole or probation? YesNo

    17. Have you ever had your license suspended? YesNo

    18. Have you ever been convicted of careless or reckless driving? YesNo

    19. Have you ever been convicted of a DUI, OUIL, MIP, etc.? YesNo

    20. Have you ever had a positive drug or alcohol screen? YesNo

    21. Are you an insulin injection dependent diabetic? YesNo

    22. Do you have Epilepsy? YesNo

    23. Do you have high blood pressure? YesNo

    24. Do you have any vision problems? YesNo

    25. Do you have any hearing problems? YesNo

    26. Do you have a lifting restriction? YesNo

    27. Do you have a sleep disorder? (Sleep Apnea) YesNo

    28. Are you currently under a Doctors care? YesNo

    29. Are you currently taking prescription drugs? YesNo

    If you answered yes to questions 10-29 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.