Box 398, Poplar, MT 59255
Administration (406) 768-6300
Fax (406) 768-6301
www. fpcc.edu
CONTINUING EDUCATION UNIT
REGISTRATION
(PLEASE PRINT LEGIBLY)
Last Name: _________________________ First Name: ______________________ MI:_____
SSN: ________/____________/_________ DOB: _________/__________/__________
Address: ___________________________ City: _________________________ ST: _______
Phone Number: ______________________ Gender: _____M _____F
Ethnicity (Check One):
_____American Indian/Alaskan Native _____Hispanic/Latino
_____Asian _____Native Hawaiian/Pacific Islander
_____Black/African American _____White/Non-Hispanic
_____Canadian First Nations
Have you attended FPCC Workshops? _____Yes _____No
Did you attend using another name? _____Yes _____No
If Yes, List Name: _____________________________________________________
Enrolled Member of any Tribe? _____Yes _____No
Name of Tribe: ________________________________________________________
Location of Tribe: City: _________________________ ST: _______
If “no” are you a descendent of an enrolled member (a parent or grandparent)?
Name of parent/grandparent ______________________________________________
Name of Tribe: ________________________________________________________
Location of Tribe: City: _________________________ ST: _______
I hereby grant permission to release tribal certification to:
FPCC P.O. Box 398 Poplar, MT 59255
Student Signature: ___________________________________ Date: ____________________
To be filled out by CEU Coordinator:
Course: ____________________________________________ #CEUs: _________________
