Application for the Provisional License Program

First Name

Middle Name

Last Name

Social Security Number

Email Address

Birthdate

Mailing Address

Country

Street

City

Region

Postal Code

Home Phone

Cell Phone

Gender

Female

Male

Colleges and universities are asked by many, including the federal government, accrediting associations, college guides, newspapers, and our own college/university communities, to describe the racial/ethnic backgrounds of our students and employees.

Which of the following do you consider to be your racial background? Please check one or more that apply:

Citizenship

Employer

Employer Address (if DHHR include the Bureau and Department)

Entry Term

Is your employer providing tuition assistance?

Yes

No

Have you taken online classes?

Yes

No

Are you proficient in online learning?

Yes

No

Provisional license number

Provisional license supervisor

Supervisor email

Resume - Although not required, you may submit a resume to supplement your application and allow us to get to know and serve you better.

AGREEMENT OF TERMS:
I certify that all of the information I have entered on this form is correct. I understand that in order to take classes that this application and all academic credentials must be on file in the Graduate Admissions Office by the application deadline established by Concord University. I understand that withholding or failing to provide accurate and complete information may result in administrative withdrawal, disciplinary action, or prosecution. I understand that I am responsible for payment of all fees for admission and enrollment or payment has been secured through agreement with a third party such as the State of West Virginia. I understand that all materials submitted for application are the property of Concord University. I acknowledge and agree that all information on the application is correct. Further, if funded by a third party, information regarding my progress in the class(es) will be made available to the third party funding the class(es).

Signature