Have you ever been licensed to drive in another state? Yes or No If yes, provide driver’s license number, state and expiration date: _________________________________ List any traffic citations you have received and any traffic accidents in you were involved. Date City & State Offense Disposition_________________________ LIFESTYLE: Any use of illegal drugs or illegal use of prescription drugs in the last 2 years will disqualify you from further consideration. Your use of drugs will be included in the polygraph examination. Please provide the information listed in the following table. DO NOT INCLUDE medication to legally prescribed you by a licensed physician for a specific ailment. Drug Never Date Used Age Maximum How Used Used (First time/Last Time) When Times Used Used Marijuana Heroin Cocaine Morphine Valium Speed Oxycontin Lortab Ecstasy Vicodin Percocet Steroids Inhalants Other(s) Other(s) Have you ever been involved in the illegal purchase, manufacture, trafficking, production, or sale of any narcotic, depressant, stimulant, hallucinogen, or cannabis? Yes or No If yes, provide the details: ________________________________________________________________ Have you ever misused or abused any drug prescribed by a licensed physician for you? Yes or No If yes, provide the details: _________________________________________________________________ Have you ever used any drug prescribed by a licensed physician for someone else? Yes or No
Have you ever been licensed to drive in another state? Yes or No If yes, provide driver’s license number, state and expiration date: _________________________________ List any traffic citations you have received and any traffic accidents in you were involved. Date City & State Offense Disposition_________________________ LIFESTYLE: Any use of illegal drugs or illegal use of prescription drugs in the last 2 years will disqualify you from further consideration. Your use of drugs will be included in the polygraph examination. Please provide the information listed in the following table. DO NOT INCLUDE medication legally prescribed to you by a licensed physician for a specific ailment. Drug Never Used Date Used (First time/Last Time) Age When Used Maximum Times Used How Used Marijuana Heroin Cocaine Morphine Valium Speed Oxycontin Lortab Ecstasy Vicodin Percocet Steroids Inhalants Other(s) Other(s) Have you ever been involved in the illegal purchase, manufacture, trafficking, production, or sale of any narcotic, depressant, stimulant, hallucinogen, or cannabis? Yes or No If yes, provide the details: ________________________________________________________________ Have you ever misused or abused any drug prescribed by a licensed physician for you? Yes or No If yes, provide the details: _________________________________________________________________ Have you ever used any drug prescribed by a licensed physician for someone else? Yes or No
EBRSO%20APPLICATION%205-2013.docx