CBI – Commercial Truck Driver Training Registration

Have you previously attended Lake Land College?
Yes No

If yes, what year did you attend?

*First Name

Middle Initial

*Last Name

Previous Name(s)

*Home Address

*City

*State

*Zip Code (5 digits)

*County

Home Phone (including area code)

Cell Phone (including area code)

Disclosure of information protected by privacy laws such as FERPA and GLBA is prohibited.

*Date of Birth (mm/dd/yyyy)

*Gender
Male Female
*Email

*Are you Hispanic or Latino?
Yes Hispanic or Latino
No Hispanic or Latino

*Are you from one or more of the following racial groups? (Select all that apply)

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*Please identify your primary racial/ethnic group (Select one)

Asian
American Indian or Alaska Native
Black or African American
Hispanic or Latino
White
Native Hawaiian or Other Pacific Islander
Choose Not to Respond

*Are you in the United States on a Visa - Nonresident Alien?
Yes in the United States on a visa
Not in the United States on a visa

Provide Home Country of Origin

Professional License number for CE

*Last High School Attended

*City of Last High School Attended

*State of the Last High School Attended

Year graduated from high school or expected to graduate

Year received GED


List ALL colleges/universities attended or now attending write “none” if you have never attended a college/university
Name

City

State


Name

City

State


Name

City

State


Highest Degree Earned
None/less than H.S. GED High School Diploma Certificate Associate Bachelor's Master's Doctoral First Professional Other Some College Unknown

Academic Program (for office use only)


Degree/Certificate Objective
Only complete one or several courses not pursuing a degree.

Transfer Intent
Do you plan to transfer to a 4 year college or university?
Yes No

Student Intent
Personal interest/self development not career oriented

Residency Status:
Have you resided in the Lake Land College District for at least the immediate past 30 days?
Yes No

If you recently moved (less than 30 days) into this community college district to establish permanent residency for reasons other than attending Lake Land College, please specify reason for move

Student Type
Are you currently enrolled full time at Eastern Illinois University?
Yes No

Apply for Term Beginning

Fall Spring Summer Summer


Course(s) Registered

NDP.CTDT

Commercial Driving License Training

Applicant Certification:

I understand that withholding information requested on this application, or giving false information, may make me ineligible for admission to the College or subject to dismissal. With this in mind, I certify that the above statements are correct and complete.

*What is the current 4-digit year? (ex. 2022)