Northern Tier Career Center

120 Career Center Lane

Towanda, PA 18848

(570) 265-8111 Fax: (570) 265-3002 www.ntccschool.org

Please complete this information and return with your tuition payment to:

NTCC Adult Education Office

120 Career Center Lane

Towanda, PA 18848

Date______

Name______

Last First Middle

Address______

Street City State Zip

County of Residence______School District______

Phone______Cell Phone______

Email______

SSN______Date of Birth______

Driver’s License Number______Issuing State______

Highest Grade Completed: 6 7 8 9 10 11 12

If you did not complete high school, do you have a high school equivalency diploma? ______

Have you attended the Northern Tier Career Center Before? ______

Gender* ____ Male ____Female

Race/Ethnicity* ____American Indian/Alaska Native Are you* ____Single Parent

____Asian or Pacific Islander ____Displaced Homemaker

____Black (Non-Hispanic) ____Economically Disadvantaged

____Hispanic ____Educationally Disadvantaged

____White (Non-Hispanic) ____Limited English Proficiency

____Disabled

*Required for Pennsylvania Department of Education reporting

Please answer the following questions: Yes No

1. In the last ten (10) years, have you been convicted of a moving violation? ______

2. Have you ever had an alcohol-related traffic violation? ______

3. Have you ever refused a breathalyzer or blood-alcohol test related

to a DUI stop or pre-employment? ______

4. Has your driver’s license been suspended or revoked in the

last ten (10) years? ______

5. Have you ever been convicted of a felony or a misdemeanor/summary

offense? ______

6. Have you ever been convicted of the use, sale and/or possession of a

narcotic drug? ______

7. Do you have heart problems, high blood pressure, or diabetes? ______

If you answered “Yes” to any of the above questions, please explain:

______

______

Are you currently covered by health and accident insurance?______

If “yes”, type of coverage______

Policy Identification Number______

Method of Payment:

Cash:____ Student Loan:____ Other/Agency:____ Caseworker’s Name:______

How did you hear about the program? Newspaper____ Radio/TV Ad____ Friend/Relative____

Website____ Other______

I hereby certify that the information that I have submitted on this form is true and accurate. I acknowledge that I am applying to enroll in a training program for a “safety sensitive” position as defined by the U.S. Department of Transportation Federal Motor Carrier Safety Administration, and as such, am required to submit to testing for controlled substances prior to acceptance into the program. Additionally, I understand that a “Yes” answer to any of questions 1 – 7; an unstable work history; or physical, mental, or social problems may hamper my efforts to obtain employment as a Commercial Driver.

Signature______

For NTCC Administrative Use Only

Enrollment Fee Received: Yes/No Amount______Check#______Date______

Tuition Received: Yes/No Amount______Check#______Date______

Act 34 Clearance Received: Yes/No Date ______

Act 151 Clearance Received: Yes/No Date ______

DMV Motor Vehicle Report Received: Yes/No Date ______

The Northern Tier Career Center is an equal opportunity education institution and will not discriminate on the basis of race, color, national origin, sex or handicap in its activities, programs or employment practices as required by Title VI and IX and Section 504. For more information, contact the Title IX and Section 504 Coordinator at 120 Career Center Lane Towanda, PA 18848-8095, (570) 265-8111.