CDL Online Education Enrollment Form

Semester	Summer 2013 Fall 2013 Spring 2014 Summer 2014 Fall 2014 Spring 2013
*Today's date
*Last name
*First name
*Middle name
Maiden name
*Email address
NOTE: Your E-mail address must be accurate as you will receive confirmation at this address.
*Home Phone
*Cell Phone
*Street address
*City
*State/Province
*Zip/Postal code
*Social Security #
*Date of Birth
Gender
Are you a US Citizen?	Yes No
Are you a Kansas Resident?	Yes No
Are you active-duty military?	Yes No
Are you a military dependent?	Yes No
Are you a Veteran?	Yes No
Do you have a driver's license?	Yes No
*Are you a current high school student?	Yes No
High School Last Attended
City		State
Graduate?	Yes No    Year of Graduation
If you did NOT graduate from high school, do you have a GED?	Yes No    Year Obtained
Associate Degree College	State: Year:
Bachelor Degree College	State: Year:
Masters Degree College	State: Year:
Doctorate Degree College	State: Year:
Current or Last Enrollment	State: Year:
Ethnic Group	Please Select an Ethnic Group Hispanic or Latino Not Hispanic or Latino
Race	Please Select a Race Group American Indian Alaska Native Asian Black or African American Native Hawaiian Pacific Islander White Other
*Is this your first On-line Course?	Yes No
Are you a first-time college student?	Yes No
Have you previously attended NCKTC?	Yes No
If Yes, dates attended (Yr.)
Are you transferring from another college?	Yes No
Are you a special student (limited hours)?	Yes No
Do you plan to earn a degree from NCKTC?	Yes No
Will you transfer after receiving your degree?	Yes No
Father's Education Level	High School Associates Degree Bachelors Degree Masters Degree Doctorate Degree
Mother's Education Level	High School Associates Degree Bachelors Degree Masters Degree Doctorate Degree
*Payment Method	Cash - In person only at NCKTC Administration Office Check - Mail to PO Box 507, Beloit KS 67420 Credit Card - Call NCKTC Cashier at 785.738.9003 Pay Pal - see below - (Complete "PAY NOW" before submitting the registration form)
NCKTC CDL TRAINING AND COURSES
You may enroll in CDL courses and training at any time. Courses and Training must be completed within 45 days after course begins. Please consult the CDL Home Page for specific course and enrollment questions.
Course	Title	Cr Hours		Instructor
CDL100	CDL Class A to include modules: Orientation, Entry Level, Pre Trip and Skills, General Knowledge, Air Brakes, Combination	1 Hr		Shamburg
CDL100	CDL Class B to include modules: Orientation, Entry Level, Pre Trip and Skills, General Knowledge, Air Brakes	1 Hr		Shamburg
CDL 110	CDL Driver Instruction - $525 Driving Fee plus $112.50 credit hour fee. (Student must contact the CDL Department to schedule driving times @ 1-800-658-4655 ext. 043)	1 Hr		Shamburg
CDL Optional Endorsements: Please Select all Endorsements that you want to enroll in. Each Module is $15. Please DO NOT include modules already offered with your CDL 100 Course
	Entry Level (2 Modules) General Knowledge (1 Module) Air Brake (1 Module) Combination Vehicle (1 Module) Double and Triple Trailers (1 Module) Hazardous Materials (1 Module) Passenger Bus (1 Module) School Bus (1 Module) Tankers (1 Module) Pre Trip and Skills for "A" Certification (1 Module) Pre Trip and Skills for "B" Certification (1 Module) Pre Trip and Skills for "B" Bus Certification (1 Module)
Note: All CDL courses must be paid for before course enrollment in completed. Students are not allowed to use Federal Financial Aid as a payment method.
Please review the information above and make sure that the information is accurate and up-to-date. Enrollment will NOT be finalized until payment is received!!
Step 2: Submit this application