student_application

Student Application

111 West Berry Street, Suite 211, Fort Wayne, IN, 46802

Application Instructions: Students must complete the application for admission and scholarships form.
Your Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Previous Name (other name under which your transcripts might appear)

First NameLast Name
Preferred Name Nickname
Date of Birth*

MonthDayYear
Date
Social Security Number*
Please verify the accuracy of your Social Security Number before submitting your application. Entering an inaccurate SSN could cause significant problems with your student record, especially if you intend to apply for need-based financial aid. While submission of the SSN is optional on the application for admission and scholarships, please note that students who have not supplied a Social Security Number to Prevail CDL Training, LLC cannot be considered for need-based financial aid.
When do you plan to enroll?*

FallSpringSummer
What is your country of citizenship*
Legal Sex*

MaleFemale
What is your county of residence
Where Were You Born
Previous Address

Street Address

CityState / Province

Postal / Zip CodeCountry
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone
Yes, I give Prevail CDL Training, LLC permission to send me important updates and information about my application status. Contact

Permission to text: methods may include text messaging and phone calls generated from an automated dialing system.
Ethnic Background

This information is optional and will not be used for discriminatory purposes.
Ethnicity

Hispanic or LatinoAmerican Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacifc IslanderWhite
Emergency Contact Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship*
Your Education
Highest Level of Education

GEDHigh School DiplomaSome CollegeCollege Degree
Signature

Clear
I understand that I am responsible for submitting complete and accurate information on my application form and in all related application materials. I certify thatthe information contained in this application form and in all application, materials is complete and accurate, and I understand that submission of inaccurate information by me or at my direction may be sufficient cause for terminating my enrollment. I understand that I am required to notify Undergraduate Admissions if any of the information provided on this application for admission changes after submission. Prevail CDL Training, LLC reserves the right to alter terms of admission, up toand including revocation of the admission offer, if necessary. Prevail CDL Training, LLC Notice of Nondiscrimination: Prevail CDL Training, an equal access/equal opportunity affirmative action institution, does not discriminate against any person in educational or employment opportunities because of race, color, religion, age, national ancestry, ethnicity, national origin, sex, pregnancy, sexual orientation, gender identity or expression, military service or veteran status, mental or physical disability, or genetic information. Retaliation is also prohibited by our policy.
Prevail CDL Training, LLC Notice of Nondiscrimination: Prevail CDL Training, an equal access/equal opportunity affirmative action institution, does not discriminate against any person in educational or employment opportunities because of race, color, religion, age, national ancestry, ethnicity, national origin, sex, pregnancy, sexual orientation, gender identity or expression, military service or veteran status, mental or physical disability, or genetic information. Retaliation is also prohibited by our policy.
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Student Application

Your Information

Ethnic Background

Emergency Contact Information

Your Education