New CDL-B Driver's License Program Application

Monroe 2-Orleans BOCES CWD

3589 Big Ridge Road, Spencerport, NY 14559

CDL-B Driver's License Program Application

General Student Information

Program

Are you a current or former student at BOCES 2?

Yes No Not Selected

First Name

Middle Name

Last Name

Gender

Ethnicity

Birth Date

Social Security No

Cell Phone

Home Phone

Street

Mailing Street2

City

State/Province

Zip/Postcode

Mailing Address (if different from physical address)

Street Address

Street Address 2

City

State

Zip Code

Employment and Education Information

This information is used to understand your needs and goals. Answers to these questions will not impact your enrollment in our programs.

High School Diploma Status

Highest Level of Education

High School (last attended)

Employment Status at Entry

Employer at Enrollment

Individual Annual Income

Emergency Contacts

Please include the name of 1-2 people to contact in the event of an emergency of if we are not able to contact you using your contact information.

Contact Name

Relationship

Cell Phone

Secondary Contact Name

Secondary Contact Relationship

Secondary Contact Cell Phone

Health Information

Please include any health information you believe we should be aware of

Hospital Preference

Any allergies to any substance?

Yes No Not Selected

If yes to allergies, please identify:

Health Problems/Concerns

How did you hear about us?

Referral Organization

Referral Individual

Class D - Driver's License

Please upload a copy of your current Class D Driver's License. PDF and JPEG formats preferred; special characters in the file name may not be allowed. Other required admissions documents can be uploaded after you submit your application.

Driver's License - Class D (uploaded from app)

Signature and Release of Information

Form Completed By: (Please Print)

Full Name Signature

Date Signed

Equal Opportunity Notice

BOCES does not discriminate on the basis of age, sex, race, religion, color, national origin, disability, creed, marital status, veteran status, military status, sexual orientation, prior criminal offense, domestic violence victim status, gender identity, gender expression, or genetic status in its programs or activities and provides equal access to the Boy Scouts of America and other designated youth groups. The following person has been designated to handle complaints/inquiries regarding the BOCES’ non-discrimination policies: Director of Human Resources, 3599 Big Ridge Road, Spencerport, New York 14559, 585-352-2420, and is also the Title VII and Title IX Officer. For further information on notice of non-discrimination, visit http://wdcrobcolp01.ed.gov/CFAPPS/OCR/contactus.cfm for the address and phone number of the office that serves your area, or call 1-800-421-3481. Please note that those wishing to file a complaint may also do so through the Department of Education’s Office for Civil Rights at https://www2.ed.gov/about/offices/list/ocr/complaintprocess.html. See also New York State Executive Law 296.

I certify that the information provided on this application is complete and accurate. I realize that failure to provide correct information is sufficient cause for reconsideration of my admission status. Release of information: By participating in this state and/or federally funded adult education and/or family literacy program, I agree to the release of the information contained in my program records, including, but not limited to, social security number, assessment results and attendance, to the New York state Department of Education (NYSED). Required information for learner participation is indicated with an asterisk (*). This information may include follow-up with employment data and other educational records and will be used in aggregated or non-personally identifiable form, for reporting as required by state and federal laws. This information may also be used for research and analysis purposes during this year and/or subsequent years. Information provided will remain secure. Unless otherwise noted, only NYSED, its authorized contractors or the local program will have exclusive access to this information.