PLEASE COMPLETE ENTIRELY. COMPLETION DOES NOT OBLIGATE YOU TO ATTEND. ONCE COMPLETED, YOU WILL RECEIVE A CONFIRMATION PAGE WITH LINKS TO A FREE IITR SCHOOL CATALOG TO DOWNLOAD FOR LATER REVIEW

PRE-ENROLLMENT QUESTIONNAIRE

PLEASE DON'T USE PUNCTUATION, UNLESS SPECIFIED.




SSN - THIS WILL BE COLLECTED FROM YOU BY THE ENROLLMENT COUNSELOR.




(ex. 97015 )

(ex. 503-123-4567 )


(ex. 010203 - MM DD YY )


(STATE ISSUED DRIVER LICENSE ID)

(ex. 0102016 - MM DD YYYY )

(ex. OR)

PLEASE ANSWER THE FOLLOWING QUESTIONS BY SELECTING YES OR NO TO QUESTIONS 2-13. IF REQUIRED, PLEASE EXPLAIN YOUR ANSWERS IN THE SPACE PROVIDED.

01) HOW MANY MOVING VIOLATIONS (TICKETS) HAVE YOU BEEN CONVICTED OF IN THE LAST 5 YEARS?
      CHOOSE NONE, OR, IF AT LEAST ONE OR MORE, GIVE THE NUMBER, AND EXPLAIN:
02) HAVE YOU BEEN INVOLVED IN ANY AT-FAULT ACCIDENTS IN THE LAST 5 YEARS?
      IF YES, EXPLAIN:
03) HAVE YOU EVER BEEN CONVICTED OF ANY MAJOR TRAFFIC VIOLATIONS? (RECKLESS, ELUDING, SPEED RACING, NEGLIGENT, CARELESS, ETC.)
      IF YES, EXPLAIN:
04) HAVE YOU EVER HAD A DRIVING OR NON DRIVING ALCOHOL RELATED VIOLATION? (OF ANY KIND)
      IF YES, EXPLAIN:
05) HAS YOUR DRIVERS LICENSE BEEN SUSPENDED OR REVOKED IN THE LAST 5 YEARS?
      IF YES, EXPLAIN:
06) HAVE YOU EVER BEEN CONVICTED OF A FELONY?
      IF YES, include details such as: when, what for, were you incarcerated. If you spent time in jail, how long? - (give start and end dates)
07) HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR?
      IF YES, when, and explain?
08) Do you have any difficulties reading, writing, or understanding English?
      IF YES, you must explain:
09) You must pass a DOT physical. Do you currently have or have you ever had any physical limitations and/or do you have any vision or hearing problems in either eye or ear? Do you have diabetes, epilepsy, seizures, high blood pressure, heart problems, mental illness, etc.? Do you have lifting limitations under 80 lbs?
      IF YES to any of the above, explain:
10) Is driving a vehicle with a clutch new to you? (You must know how)(If you are not experienced using a clutch, we will explain a possible option for you.
      IF YES, meaning you think it will be a problem, explain:
11) You may need to verify your 10 year work history. Will this be a problem?
      IF YES, EXPLAIN:
12) DMV/DOT requires you provide a birth certificate or passport. Can you do so?
      IF NO, you can't provide the documents, explain:

13) Are you a U.S. Citizen or permanent legal resident of the U.S.? By Law, you must be a U.S. Citizen or Permanent Legal Resident to obtain a CDL
      IF NO, explain:


14) What is your educational background? (You will be required to provide proof)

Education History



College Experience

15) What source of advertisement brought you to IITR?




17) What type of employment would you like if you attend and graduate?

18) If I attend, I plan to pay my tuition by the method selected below:

19) If applying for an IITR Internal Student loan: My Credit is:

If you have poor credit, can you obtain a cosigner?      

20) Mandatory questions required by our Licensing Agencies

Race:

Gender: