Application for Application

Truck Driving School

OFFICIAL APPLICATION
After submitting application please contact the Transport Training office at the following number to ensure enrollment (1-800-541-2891).

Crowder College Transport Training 601 Laclede Neosho MO 64850

Phone: 1-800-541-2891

Fax: 417-455-5680

Non-refundable enrollment fee of $100
Your application will not be validated until receipt of all documents is complete.
You will be attending truck driving school... * Fall - Mid August - December Spring - January - Early May Summer - Late May - Early August
The school year is divided into three segments called semesters: Fall, Spring and Summer. Truck Driving School doesn't correspond to semesters but to be kind to the central office computers please make an educated guess - it does not have to be exact. You will fill in which class you are taking at the end of the form.
Year of Enrollment *

Type in the year you plan to be attending Crowder College.
I. PERSONAL INFORMATION
To be completed by all students
First Name
Middle Name
Last Name
Former Name if Any First Last
If you have had another name you used such as a maiden name please supply that here.
Social Security Number - no dashes - *

Please supply us with your Social Security number.
Birth Date *

Please put in the Month then the Day and the Year separated by dashes like so 4/19/1983
Marital Status * Married Single Divorced Widowed
Email

If you have an email address please let us know.
Mailing Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Please let us know your mailing address.
Permanent Mailing Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

If you may be moving or are just temporarily at your mailing address please also provide us with a permanent mailing address. A good example of a permanent mailing address would be your parents house.
How long have you lived at your permanent legal residence? *

Please supply the number of years/months you have lived at your permanent legal residence.
How long did you live at your former legal residence? *

Please supply the number of years/months you lived at your former legal residence.
Home Phone - (###) - ### ####
Cell Phone - (###) - ### ####
County in which you reside *
School District in which you pay property taxes
Have you ever been convicted of a felony, misdemeanor or other crime? If yes, explain
Race: (Optional) Hispanic / Latino White Black / African Amercian Asian American American Indian / Alaska Native Hawaiian Native / Pacific Islander
Citizenship * U.S. Permanent Resident Alien Other
If you specified 'Other' under Citizenship above please explain:

Use this only if you specified "Other" under Citizenship above.
Language:
DOT requirement: FMCSR 40 subpart B part 391.11 (b)(2) Applicant must speak, read and write and communicate in English.
* English Other
If you specified 'Other' above please list your native language here:

If your native language is not English or Spanish, please let us know what it is here.
Student Status * FT First time student at any college since completing high school, including Crowder Dual Credit or Tech Prep FR Former student at Crowder College TR Transfer Student(prior credit at another institution but first time at Crowder College) TS Transient Student (non-degree seeking at Crowder; taking one or more classes to transfer to another institution)
Student Classification * HS High School Student-Dual Credit FR Freshman (0-30 hours) SO Sophmore (31-60 hours) PJ Post Junior College (65+ hours) PB Post Baccalaureate SP Special (no GED or High School Diploma-6 hr cumulative maximum)
HIGH SCHOOL / G.E.D. INFORMATION
Your High School or GED Graduation Date / MM / DD YYYY
MM= Month, DD=Day, YYYY = Year
Choose your High School, GED, Home School, Non-Graduate or Other *

Please select your High School - if your school is not present please select 'other' from the list then continue.
If you chose 'Other' under High School, Name of School:
Name of High School, City, State
Did you attend or participate in the Missouri A+ Schools Program? Yes No
The "A School" program was established in 1993 by state law. http://dese.mo.gov/divimprove/aplus/proginfo/abtaplus.html
COLLEGE INFORMATION
List all colleges and/or universities which you have attended. Official transcripts of all degree-seeking students are required to be on file by the fourth week of the semester.

If you are transferring in credit hours obtained at other Colleges/Universities you need to list them here.
Name of College, City, State, Year(s)
Example College, Neosho, MO
Please list all your higher education here along with the name of the facility, city, state and year(s) attended. Skip a line for new entries.
Have you been a member of the armed forces? - Information is used only to provide you with additional information on transfer of military credits Yes, I have been a member of the armed forces. No, I have not.
Are you in good disciplinary standing at your former institution and can you return without restrictions? Yes No
Are you in good academic standing at your former institution? Yes No
Program of Study
Check the Box
* 49.0205 Transport Training
III. EMERGENCY INFORMATION
Person to Contact in case of Emergency First Last
Emergency Contact - (###) - ### ####
Physicians Name First Last
Physician's Phone Number - (###) - ### ####
Hospital you wish to be transported to in case of emergency:
1. In case of an emergency, I authorize college personnel in charge to use their discretion regarding the college's emergency procedures. I understand that falsification of any information provided on this application will subject me to disciplinary action, which may result in my dismissal from the college.

2. I certify that the answers given in this application are complete and accurate to the best of my knowledge, and I understand that submission of false information may result in my denial or suspension.
*

Please type in your name, this counts as your legal signature!
Date * / MM / DD YYYY
Please choose a security question below: * What is your favorite movie? What is your favorite flavor of ice cream? What is your favorite sports team?
Answer to your security question: *
Truck Driving Specific Form
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CDL Permit # (Class A Permit Required upon first day of class.) *
Drivers License #
Drivers License State
Class You Would like To Enroll In: *

Please select which five week course you are interested in attending.
IV. REMINDER AND INFORMATION
After submitting application please contact the Transport Training office at the following number to ensure enrollment (1-800-541-2891).

Crowder College Transport Training 601 Laclede Neosho MO 64850

Phone: 1-800-541-2891

Fax: 417-455-5680

There is no application fee.
Your application will not be validated until receipt of all documents is complete.

Crowder College - Truck Driver Training

601 Laclede Ave. Neosho, MO 64850
Toll Free 800-541-2891 FAX: 417-455-5680

Crowder College is an equal opportunity/affirmative action/educational/employment institution, and is nondiscriminatory relative to race,religion, color, national origin, sex, age and qualified disabled. Crowder College is committed to providing educational opportunities to all qualified students regardless of their economic or social status and will not discriminate on the basis of handicaps, race, color, sex, creed or national origin. Nicole Striegel, Dean of Student Services,coordinates efforts to comply with the provisions of Title VI of the Civil Rights Act of 1964,Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973.

Truck Driving School

Truck Driving School

I. PERSONAL INFORMATION To be completed by all students

HIGH SCHOOL / G.E.D. INFORMATION

COLLEGE INFORMATION List all colleges and/or universities which you have attended. Official transcripts of all degree-seeking students are required to be on file by the fourth week of the semester.

III. EMERGENCY INFORMATION

Truck Driving Specific Form -----------------------------------------------------------------

Crowder College - Truck Driver Training

I. PERSONAL INFORMATION
To be completed by all students

COLLEGE INFORMATION
List all colleges and/or universities which you have attended. Official transcripts of all degree-seeking students are required to be on file by the fourth week of the semester.

Truck Driving Specific Form
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