NCDOT Materials & Tests Unit: Soils Laboratory: NCDOT Student Information Form

Student Contact Information:

Name:   Date:

Job Title:   Last 4 Digits:

Student Home Mailing Address:

Street:

City:   State:   Zip:

General Information:

Contact Person:   Email Address:

Resident District Engineer:   Division:

Mailing Address:

Street:

City:   State:   Zip:

Desired Class:

Place a "X" in the Requested Class(s) box for each Full Training Class you wish to attend. Place the amount of fee in the Applied Application Fees box. Total application fees at the bottom of the table. If the student has previously attended and successfully completed the class then he/she may take an On-line Self-Study Course(s) place a "X" in the Self-Study Course(s) box for each class you wish to take. Place the amount of fee in the Applied Application Fees and total fee(s) at the bottom of the table.

Full Training Class Option:

Check Here Desired Class Application Fee Applied Application Fees

ABC Sampling School $50.00

Borrow Pit Sampling School $50.00

Conventional Density School $100.00

Nuclear Safety Haz. Materials N/A N/A

Total of application fees for requested classes (amount of check):

On-line Self-Study Course Option:

Check Here Desired Class Application Fee Applied Application Fees

ABC Sampling School $25.00

Borrow Pit Sampling School $25.00

Conventional Density School $25.00

Nuclear Safety Haz. Materials N/A N/A

Total of application fees for requested classes (amount of check):

Cost Center Number:

Have you ever been previously certified in any of the schools listed above?   Yes    No

If "YES", what is your HiCAMS Certification Number?

NOTE: Send the original student information sheet with a non-refundable application fee payable to:
NCDOT Materials and Tests Unit

Class sizes are limited. Submission of this form does not guarantee a slot in the desired class.

Mail completed form and check or money order to:

Mehdi Haeri, Soils Engineer
1801 Blue Ridge Road
Raleigh, NC 27607

If you have any additional questions please contact Mehdi Haeri or Jim Sawyer at (919) 329-4150.


		The North Carolina Department of Transportation