CDL Registration Form

*First Name

Middle Initial

*Last Name

Previous Name(s)

*Home Address

*City

*State

*Zip Code

*County

Home Phone (including area code)

Cell Phone (including area code)

*Email

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

*Date of Birth

*Gender

Demographic Information

*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)

Asian

American Indian or Alaska Native

Black or African American

White

Native Hawaiian or Other Pacific Islander

Choose Not to Respond

License Information

School Information

*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

Residency Information

*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:

The College is required to collect information related to student citizenship in order to determine eligibility for in-district or in-state tution and other educational benefits.

*Please choose one of the following options I am a U.S. citizen
I am a permanent resident of the U.S.
I am a Visa Holder
Other
I choose not to respond. Failure to respond will result in being charged out-of-state tuition rate.

Provide Home Country of Origin

*Do You Certify?

I certify that the information I have provided related to my citizenship status is complete and accurate. I understand that failure to provide complete and accurate information may impact my eligibility for in-state/in-district tuition and/or may subject me to disciplinary consequences.

Additional Information

For Office Use Only

Academic Program: NDP.CTDT
Degree/Certificate Objective: Only complete one or several courses not pursuing a degree.
Transfer Intent: No
Student Intent: 2. To improve skills
Course(s) Registered: NDP.CTDT Hazardous Materials Endorsement (CDL 030)