DOT - REQUEST FOR CDL REIMBURSEMENT APPROVAL

REQUEST FOR CDL REIMBURSEMENT APPROVAL
North Dakota Department of Transporation, Civil RIghts
SFN 62604 (2-2025)
North Dakota Department of Transportation, Civil Rights

Instructions: Submit one completed request for each student. Include the acceptance letter from the program you will be attending. Provide proof of gender/ethnic group: tribal membership, birth certificate, driver's license, passport, etc. For Economically Disadvantaged designation, NDDOT will contact applicant for required documents.
CDL STUDENT CONTACT INFORMATION
Contact Name*
Email Address*
example@example.com
Telephone Number*
Address*

Mailing Address

Street Address Line 2

CityState

ZIP Code
Gender*

MaleFemale
Ethnic Group Designation (check one)*

CaucasianBlackHispanicAmerican Indian or Alaskan NativeAsian or Pacific IslanderEconomically Disadvantaged
File Upload

Cancelof
SITE INFORMATION
Site Name*
Number of Program Hours*
Date Class Begins*

MonthDayYear
Date
Date Class Ends*

MonthDayYear
Date
Address*

Program Address

Street Address Line 2

CityState

ZIP Code
ONSITE PROGRAM CONTACTS
Program Instructor*
Program Instructor Email*
example@example.com
Notes*
*Program Instructor: On-the-Job Training Supportive Service (OJT SS) staff will contact this person weekly.
APPROVED: North Dakota Department of Transportation
Signature - OJT Program Administrator*
Date*

MonthDayYear
Date
Should be Empty: