Lake Superior College

Lake Superior College, Emergency Response Training 11501 Hwy 23, Duluth, MN 55808 Tel: 218-733-1074, Fax: 218-733-1094

Name of Fire Department ______(if applicable)_ Date ______

This form is specifically for the CPAT Certification Tests. Candidates will be directly billed a fee of $125.00.

Name______Last First MI (Previous Name if applicable) Home Address______City______State_____ Zip______

Resident of MN  Yes  No County______Email Address______

Home Phone ______Work/Cell ______

Request for Confidential Information Please fill your Birthdate. Providing the following information is voluntary. Classes may be tax deductible under Hope Scholarship and Life-Long Learning tax laws. Your social security number must be provided in order for you to either of these deductions. *Many colleges/universities use social security numbers for student identification purposes on student records. Providing your social security number, birth date, gender, and ethnic background is voluntary. If you do not provide this information, your application will still be processed. This data is requested for purposes of administration, program evaluation, and consumer and alumni data. The data may also be used to create summary information about MnSCU programs through data matches with other state agencies tax laws. Social Security #______Birthdate ______Gender: Male ____ Female ____ Race and Ethnic Background (select any that apply): (0) Unknown (5) Hispanic or Latino (1) Black or African American (6) American Indian or Alaska Native (2) Asian (7) Native Hawaiian/or other Pacific Islander (3) White Course Registration Information Course ID#/Title: CPAT Cert test Date/Time/Location: ERTC 11501 Hwy 23, Duluth, MN 55808 Fee: $125.00

The Lake Superior College Student Code of Conduct Procedure 3.6.1 applies at all locations of the college and all college activities and classes wherever located. PAYMENT SOURCE: Please list Company information for billing purposes if needed. If you are a self-pay, please complete or attach your check.

Please bill my:  Personal Credit Card     Expiration Date: ______Account #:______Student ID#:______Company name and address ______Signature: ______Individuals with disabilities may request reasonable accommodations or information by contacting Georgia Robillard at 218-733-7650 or 218-722-6893/TTY. This document can be made available in alternative formats by contacting Disability Services, E2114, at 218-733-7650 (voice) or 218-722-6893 (TTY). (AD/12/07)

This will be credited to cost center 015040