Page 1 of 2 Form no. 04676 CS-EDU Rev. 8/2018
Application for Adult Education Services
Contact information:
Full legal name (first, middle, last, suffix):
Ethnicity:
Asian Black Hispanic Native American
White Other: __________________________
Tribal affiliation (if Native American):
Tribal affiliation – If Native American, submit Chickasaw citizenship card/certificate or verification as an enrolled member of a federally
recognized tribe.
Did someone refer you to our program? Yes No
If yes, which agency referred you to our program?
Are you a Chickasaw Nation employee? Yes No
If yes, in what department are you employed?
Background Information:
Last public school attended:
What year did you
drop out?
Did you attend special
education classes?
Yes No
Other adult education programs attended (when & where):
Has the Chickasaw Nation ever paid for your HSE testing?
Yes No If yes, what year? __________
Have you ever been convicted of a felony or misdemeanor? Yes No
Do you have any disabilities or handicaps that require special services? Yes No
If yes, briefly describe:
Certification – I certify that the information provided on this form is true and correct.
Guardian’s signature (if under 18):
The Chickasaw Nation Supportive Programs and the applicant agree to strictly maintain the confidentiality of all information disclosed hereunder, or any amendments thereto. The
parties agree that the information contained in said application shall be considered “Confidential Information” and shall not be disclosed to third persons, except upon written
consent of the applicant or as otherwise required by law.
Education Division
Adult Learning Program – DOUGLAS H. JOHNSTON BUILDING
300 Rosedale Road / Ada, OK 74820 / (580) 421-7711 / Fax (580) 272-1224
