Dalhart CDL Registration FormName* First Middle Initial Last Social Security Number* Date of Birth* Month Day Year Gender* Male Female I prefer not to answer Phone*Email* Current Address* Current Address City State / Province / Region ZIP / Postal Code ADA Accommodations?* Yes No Resident Status* Texas Resident Out-Of-State Resident Foreign Citizen Ethnic Origin* American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Prefer not to answer Are you employed? No Yes If yes, with who? CDL Courses and EndorsementsPlease select the class or classes you wish to enroll in below. If you have multiple classes you would like to attend, please make all selections before finishing this form. CDL - STUDENT STATUS New Student - Self-Pay New Student - Company Pay Instructor CDL 5-Week Course - Class Dates$3,700.00CHOOSE A CLASS DATEApril Class (begins 4/18/23)May Class (begins 5/23/23)August Class (begins 8/1/23)September Class (begins 9/5/23)October Class (begins 10/10/23)November Class (begins 11/14/23)HiddenCDL Hazmat Endorsement - Class Dates$250.00CHOOSE A CLASS DATENov 2022 (11/7 thru 11/20)Dec 2022 (12/5 thru 12/18)HiddenCDL School Bus Endorsement - Class Dates$250.00CHOOSE A CLASS DATENov 2022 (11/7 thru 11/20)Dec 2022 (12/5 thru 12/18)HiddenCDL Passenger Endorsement - Class Dates$250.00CHOOSE A CLASS DATENov 2022 (11/7 thru 11/20)Dec 2022 (12/5 thru 12/18)CDL 5-Week Course - DatesCHOOSE A CLASS DATEApril Class (begins 4/18/23)May Class (begins 5/23/23)August Class (begins 8/1/23)September Class (begins 9/5/23)October Class (begins 10/10/23)November Class (begins 11/14/23)HiddenCDL Hazmat Endorsement - DatesCHOOSE A CLASS DATENov 2022 (11/7 thru 11/20)Dec 2022 (12/5 thru 12/18)HiddenCDL School Bus Endorsement - DatesCHOOSE A CLASS DATENov 2022 (11/7 thru 11/20)Dec 2022 (12/5 thru 12/18)HiddenCDL Passenger Endorsement - DatesCHOOSE A CLASS DATENov 2022 (11/7 thru 11/20)Dec 2022 (12/5 thru 12/18)Total $0.00 Payment Method***Online payment is the preferred method of payment** If you need to pay in person, please exit this form and go to FPC Rahll campus front desk prior to the first day of class to fill out the form manually and set up payment. Pay Online Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Finals Steps:Consent*This will serve as your digital signature for the course(s) you enroll in. I certify that the information given above is complete and correct.Drug Testing*I understand that enrollment in the CDL course will subject me to random drug testing. I acknowledge that I have been informed about the random drug testing policy for the CDL course.