CENTRAL CAROLINA TECHNICAL COLLEGE
Workforce Development and SC Environmental Training Center
REGISTRATION FORM
Mail: Central Carolina Technical College
SC Environmental Training Center
506 N. Guignard Drive, Sumter, SC 29150
9787-877-308:xaF6566-877-308 :enohP
Email: etc@cctech.edu
NAME:
COURSE NAME:
COURSE DATE:
COURSE COST: ONLINE: [ ] YES [ ] NO
A B C DSHORT SCHOOL LEVEL
(CHOOSE ONE)
(WATER & WASTEWATER OPERATORS ONLY)
SEX: [ ] M [ ] F US CITIZEN: [ ] YES [ ] NO
WORK PHONE:
CELL PHONE:
HOME PHONE: FAX #:
MAILING ADDRESS:
CITY: COUNTY:
STATE: ZIP:
COMPANY NAME:
EMAIL ADDRESS:
NAME on CARD:
CARD EXP: SECURITY CODE #
CARD BILLING ADDRESS:
E
PAYMENT INFORMATION:
[ ] CHECK (Payable to: Central Carolina Technical College)
[ ] CREDIT CARD
(CHOOSE One) VISA MC AE
I, ________________________________________________ hereby authorize CCTC to charge the credit card
listed below according to the terms outlined above. This payment authorization is for the training/services described
above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user
of this credit card and that I will not dispute the payment with the credit card company; so long as the transaction
corresponds to the terms indicated in this form.
REFUNDS: A full refund will be issued for all courses, seminars and workshops canceled by Central
Carolina Technical College. Registrations canceled before the cutoff date, ten (10) working days before the
scheduled training, will be assessed a 20% administrative fee. There will be no refund for a cancellation less
than ten (10) working days prior to the start date. Refunds may be requested by mail, email, in person or by
telephone. These requests are the responsibility of the registrant.
Confirmation or receipt available upon request. Call 803-778-6656 or email etc@cctech.edu
ETHNICITY: African American__ American Indian__ Asian__ Hispanic__ White__
CREDIT CARD #
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
DATE of BIRTH:
LAST 4 DIGITS of SOCIAL SECURITY:
(REQUIRED)
(REQUESTED)
