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CBI – Commercial Truck Driver Training Registration


Yes No

















(5 digits)



(including area code)

(including area code)

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

(mm/dd/yyyy)


Male Female


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


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


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


Yes in the United States on a visa
Not in the United States on a visa
















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



























Only complete one or several courses not pursuing a degree.


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


Personal interest/self development not career oriented


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




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



Fall Spring Summer



NDP.CTDTCommercial 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.