Center for the Global Learner Registration Form
Complete the form below and email or fax it to:
Email: cgl@durhamtech.edu Fax: 919-536-7277
• Payment or payment authorization must be received before the
first class.
• The refund policy can be found at
durhamtech.edu/continuing-education/cancellations-and-refunds
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:
Country of Birth: _______________
Highest education level completed Gender
Native Language: __________________
(Check one)
❒ Female ❒ Male
Registration fee exemption
❒ Non-graduate
(highest grade completed) Race
❒ Durham Tech employee
(Check all that apply)
❒ GED
❒ Other________________
❒ American/Alaska native
❒ High school diploma
❒ Asian
Employment status
❒ Adult high school
❒ Black/African-American
❒ Full time (40 or more hours/week)
❒ Vocational diploma
❒ Hawaiian/Pacific Islander
❒ Part time (39 or fewer hours/week)
❒ Associate’s degree
❒ Hispanic/Latino
❒ Retired
❒ Bachelor’s degree
❒ Non-Hispanic/Non-Latino
❒ Unemployed (not seeking)
❒ Master’s degree or higher
❒ White
❒ Unemployed (seeking)
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
click to sign
signature
click to edit
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