Road Scholar Enrollment Form

Indiana LTAP Road Scholar Program
Enrollment Form
Thank you for your interest in becoming an Indiana LTAP Road Scholar. Please provide the
following information for enrollment in the program.
Please print or type
Name: _____________________________________________________________
First
Middle Initial
Last
Title: _______________________________________________________________
Agency: ____________________________________________________________
E-Mail:_____________________________________________________________
Please list the number of years of service in a highway, street, or engineering department(s).
(Note: Credit is given for employment with a local government agency/office. Credit is awarded as 30 points per
year, up to a maximum of ten years, or 300 points.)
Start Date: ____________________End Date:
Agency:
Start Date: ____________________End Date:
Agency:
Start Date:
End Date:
Agency:
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List all LTAP training events you have attended in the last five years. (Workshops, conferences, and
demonstrations)
Workshop/Conference
Year Attended
Please complete and return to:
Indiana LTAP
3000 Kent Avenue, Suite C2-118
West Lafayette, IN 47906
Fax: (765) 496-1176
Email: [email protected]
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