Adult Education Registration Form
Term
SSN* or Student ID Number Legal Name (Last, First, MI) Suffix
*If you have attended PSC in the past, use your ID number. Use your SSN if you have never attended PSC. Review the SSN Collection
and Usage Statement provided.
Date of Birth (Month/Day/Year)* Primary Telephone Number Secondary Telephone Number
Address City State
Zip
County of Residence Personal Email Address
Email: You will be provided a College email address. Please access your Pirate Mail on the College web site by clicking on the PirateMail icon. You must
check your Pirate Mail at least once a week.
Pensacola State College does not discriminate on the basis of race, color, national origin, sex, disability, age, ethnicity, religion, marital status, pregnancy, sexual orientation, gender identity or genetic
information in its programs, activities and employment. For inquiries regarding the College’s non- discrimination policies, contact the Executive Director of Institutional Equity and Student Conduct,
1000 College Boulevard, Building 5, Pensacola, Florida 32504, (850) 484-1759
Revised 1/29/2020
I affirm that the information provided in this application is true and accurate. I understand that enrollment information and test
scores may be released for federal and state reporting requirements. I have been provided the Social Security Collection and
Usage Statement.
Si Signature __________________________________________ Date_____________________
TABE Reading __________ Language ________________ Math ________________
GE/ Level Form GE/ Level Form GE /Level Form
CASAS Reading _________________
Listening ________
SS/Level Form SS/Level Form Test Date____________________
1. Corrections 2. Community Corr. Program 3. Other Institution Setting
Seperation date to be provided by instructor when student completes class or ceases attending class.
