IMPORTANT: Please print clearly, respond to all questions completely, and sign registration form.
Incomplete or unsigned Registration Forms cannot be processed!
(*Used for reporting purposes only)
Social Security #:
Last First Middle
Street, P.O. Box, Route City State Zip Code
County of Residence:
Date of Birth:
Month Day Year
1. Female 2. Male
1. American/Alaska Native 2. Asian 3. Black or African American
2. Non Hispanic/Latino
4. Hawaiian or Pacific Islander 5. White
The highest education level that best describes you:
0 1 2 3 4 5 6 7 8 9 10
(Highest Grade Completed – Non-high School Graduate)
(High School Graduate)
-- GED or High School Equivalency 16 Bachelor’s Degree
13 Adult High School Diploma 17 Master’s Degree or Higher
Part-Time (PT) Retired (R)
Unemployed – Not Seeking (UN)
Unemployed – Seeking (US) Inmate
No confirmation will be sent.
You will be notified only if the class is full or cancelled.
Total Payment: $
Card Holder’s Name:
Card Holder’s Signature:
Exp. (MM / YY)
Colleague ID Number :
Post Office Box 309, Jamestown, NC 27282
Please check one:
BY MY SIGNATURE, I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT.
*Make check or money order payable to: GTCC
I certify that I am at least 18 years old and not enrolled in public school or I am under 18 and have provided a Minor Release
Form to the Continuing Registration Office