Fillable CONTINUING EDUCATION REGISTRATION FORM Please check if this (Durham Technical Community College)

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CONTINUING EDUCATION REGISTRATION FORM Please check if this (Durham Technical Community College)

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The CONTINUING EDUCATION REGISTRATION FORM Please check if this (Durham Technical Community College) form is 1 page long and contains:

  • 1 signature
  • 26 check-boxes
  • 92 other fields

Country of origin: US
File type: PDF

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CONTINUING EDUCATION
REGISTRATION FORM
• Payment or payment authorization is required at time of registration and must be received before the first class.
• Receipts or confirmations will not be sent for payments that are faxed or mailed.
• Review Course Cancellation and Refund procedures
• View course offerings
Last name: ________________________________________ First name: ________________________________________ MI:________
Address: _________________________________________ City: ____________________________ State: ______ Zip: _____________
County:
❒ Please check if this is a new address or change in information.
Home: (_____)____________________ Business: (_____)_____________________ Ext: _______ Cell: (_____)_____________________
Colleague ID #: ___________________________ (assigned by college if new student) Date of birth: _____/____/____
Email address: ___________________________ _____________________
Highest education level completed Gender Registration fee exemption
(Check one)
❒ Female ❒ Male ❒ Durham Tech employee
❒ Non-graduate
(highest grade completed) _______ Race
❒ Other _____
❒ GED
(Check all that apply)
Employment status
❒ High school diploma
❒ American/Alaska native
❒ Full time (40 or more hours/week)
❒ Adult high school
❒ Asian
❒ Part time (39 or fewer hours/week)
❒ Vocational diploma
❒ Black/African-American
❒ Retired
❒ Associate’s degree
❒ Hawaiian/Pacific Islander
❒ Unemployed (not seeking)
❒ Bachelor’s degree
❒ Hispanic/Latino
❒ Unemployed (seeking)
❒ Master’s degree or higher
❒ Non-Hispanic/Non-Latino
❒ White
Course Number Course Title Location M T W Th F Sa Su Start Time End Time Start Date End Date Cost
College Employee Signature Date
Check #: Bank:
Credit Card #:
❒ AMEX ❒ DISCOVER ❒ MC ❒ VISA
Cardholder Name: Exp. Date: / (MM/YY) Credit Card Security #:
FOR OFFICE USE ONLY•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
ID #: Name: Term: Cost:
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CONTINUING EDUCATION REGISTRATION FORM Please check if this (Durham Technical Community College)

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Completed 26 July 2020

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