ELDT Program Application – Certified Safe Driver, Inc.

1 · Applicant Information

Full Name

Suffix

First Name *

Middle Name

Last Name *

Contact Details

Phone #

Cell Phone #

Trainee Type

New Trainee Re-Entry Trainee

Address

Street Address

City

State

Zip Code

Email & Date of Birth

Personal Email Address

2nd Email Address (Optional)

Date of Birth

License / ID Information

Current License #

State

Class

License Expiration

Permit Expiration (Optional)

SS # (If Needed)

2 · License Upgrade Request

Seeking License Upgrade To – Class

Class A Class B Class C

Endorsements

(N) Tank Vehicles (H) Hazardous Materials (X) Combo Tank/HazMat (T) Double/Triple Trailers (P) Passenger (S) School Bus

Restrictions to Remove

Air Brake 5th Wheel Manual Vehicle

3 · Prior to Starting Requirements

4 · Training Schedule

Theory & Pre-Training Program

Start Date

Finish Date

Practical Behind-the-Wheel Training

Start Date

Finish Date

5 · Training Services & Estimated Costs

Theory & Pre-Training Services

Service	Est. Cost	Select
Medical Exam – Drug Screening	$200
Permit Test Support (incl. FMCSA Clearinghouse & Document Entry)	$95
Theory Training (Online)	$105
Theory & Pre-Training Total Estimated Cost	$0

Practical Training Services

Service	Est. Cost	Select
DMV Practice Test & Pre-Trip Wording and Quiz	$150
Defensive Driving Presentation	$149
ELDT CDL Practical Training – DMV Skills Test	$2,300
Practical Training Total Estimated Cost	$0

Optional Extra Services

Service	Rate	Select
Truck Rental – Practice & Accrue Drive Hours	$75.00 / hr
DMV Re-Test	$75.00 / hr

Total Adjusted Cost $0

Specified Payment Terms

6 · Cancellation, Withdrawal & Refund Policy

Trainee's Right to Cancel

Trainees have the right to cancel their agreement for a program, without any penalty or obligations, up to two days prior to the first training session. Cancellation must be submitted in writing to: 4000 Valley Blvd #104 Walnut, CA 91789, or via the CSD official email address with acknowledgement received.

If the Enrollment Agreement is cancelled, CSD, Inc. will refund the Trainee any money paid, less the registration fee not to exceed $250.00, within 45 days after the notice of cancellation is received.

Withdrawal from the Program

Trainees may withdraw at any time after the cancellation period and receive a pro-rated refund if they have completed 60% or less of the scheduled hours through the last day of attendance. If more than 60% is completed, tuition is considered earned and no refund will be issued.

Understandings

Location of Instruction: 4000 Valley Blvd. #104 Walnut, CA 91789. All training is in-person; no distance training is offered. Questions may be directed to the Bureau for Private Postsecondary Education (BPPE) at 1747 N. Market Blvd Suite 225, Sacramento, CA 95834, www.bppe.ca.gov, toll-free (888) 370-7589 or fax (916) 263-1897.

Transferability: The transferability of scores or hours earned is at the complete discretion of the institution to which you may seek to transfer.

Student Tuition Recovery Fund (STRF): California residents who prepay training cost may be eligible for STRF protection. See full agreement for details.

7 · Agreement & Signature

Payment Agreement: You are responsible for the total cost payment including the total adjusted cost as specified in the payment terms. The terms and conditions of this agreement are not subject to modification by oral agreement. This agreement is a legally binding instrument when signed by the student and a representative of Certified Safe Driver, Inc.

I certify that I have received the catalog, Program Performance Fact Sheet, and information regarding completion rates, placement rates, license examination passage rates, salary or wage information, and the most recent three-year cohort default rate. I have read, understand, and agree to all terms and conditions contained in this enrollment agreement.

Student Signature

Signature

Print Name

Date

CSD Representative

CSD Representative Signature & Title

Date