Truck Driving Program
Application for Admission
601 Laclede Neosho, MO 64850
Phone: 800 541-2891


1. Application submitted for class date four week class
2. Complete legal name:

Last First Middle

Former Names (if any):

3. Social Security Number:
4. Permanent Home State and Country
State Country

5. Marital Status: Married Single
 6. Sex: Female Male

7. Permanent Legal Address:
Street Address
City State Zip Code
County Area Code Phone Number

8. How long have you lived at your permanent legal address? years months

9. Are you a United States Citizen? Yes No
10. Race: White Black Asian/Pacific Islander
Hispanic American Indian/Alaskan Native Other

11. Date of Birth

12. Date of enrollment at Crowder College - Month Year

13. Student Status: First time student at any college
Former student at Crowder College
Have you attended another institution since attending Crowder? Yes No
Transfer student (prior credit at another institution but first time at Crowder College)

14. High school
Transcripts or GED scores are required of all students enrolling for three (3) hours or more of college credit
GED: I completed the GED equivalency test in the state of
Month/Year of test

15. Classification: Freshman (0-30 hours) Special (no GED or High School Diploma)
Sophomore (31-64 hours) Post junior college (65 hours or more)

16. I am degree seeking and my program of study is the Truck Driving / Certificate Program

Medical Needs and Emergency Information

19. Please check if you have a problem that might interfere with class performance
Writing Hearing
Walking Seeing

20. Please check if you have
Diabetes Epilepsy or seizures Hemophilia
Heart Disease Asthma Frequent or severe headaches
Other (Please explain)

21. Do you have any allergies or have you reacted unfavorably to any drug, medicine, or other substance? Yes No
If yes, please explain

22. Have you had the measles or the measles vaccination?
Yes No
23. Are all of your immunizations current? Yes No

24. Please indicate any other medical or physical information that Crowder College officials should know


25. In case of emergency contact Parent Guardian Spouse
Name
Street Address
City State Zip Code
Telephone Number

26. Physician to contact in case of emergency Phone Number

27. Name and phone number of hospital you wish to be transported to if needed
Phone Number

In case of 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 Crowder College.

Name Date

In the absence of a written signature, if you agree to the above terms, please select the SUBMIT button below.

28. CDL Permit # (Class A permit required)

29. Drivers License # and State

30. How will you be funding your school expense?
Cash/Check Credit Card JTPA/PIC Other

31. Do you plan to reside in the dorms? Yes No