DOT - CDL REIMBURSEMENT PROGRAM COMPLETION

CDL REIMBURSEMENT PROGRAM COMPLETION
North Dakota Department of Transporation, Civil RIghts
SFN 62607 (2-2025)
North Dakota Department of Transportation, Civil Rights

INSTRUCTIONS: CDL students who have successfully completed their CDL program must complete this form to be eligible for the CDL Completion Reimbursement.

This form must be fully completed, dated, and signed, and include a current W-9 form. A certificate of completion from the program must be attached.

If you need assistance completing this application, please contact us at: (701)328-3116.

NOTE: Submission of this form does not guarantee payment and is subject to funding availability.
STUDENT INFORMATION
Student Name*
Address*
Telephone Number*
Email Address*
example@example.com
Contractor / Employer*
CDL PROGRAM DETAILS - TO BE FILLED OUT BY STUDENT
Program Site*
Date of Completion*

MonthDayYear
Date
Program Hours*
CDL Training Program Name*
A W-9 will be required with this form to process payment. The form can be found online at: www.irs.gov. Incomplete or partially completed forms cannot be processed.
File Upload*

Cancelof
Applicant Signature (e-signature accepted)*
Date*

MonthDayYear
Date
THIS SECTION FOR NDDOT USE ONLY
NDDOT Authorized Signature*
W-9 Received*
Approved Amount*
Notes*
Date*

MonthDayYear
Date
Should be Empty: