Revised. 6/2015
IMPORTANT: Please print clearly, respond to all questions completely, and sign registration form.
Incomplete or unsigned Registration Forms cannot be processed!
Course:
Number (Code)
Title
Date:
Begin End
(*Used for reporting purposes only)
Social Security #:
Name:
Last First Middle
Address:
Street, P.O. Box, Route City State Zip Code
County of Residence:
Date of Birth:
Month Day Year
E-mail Address:
Phone:
Sex:
1. Female 2. Male
Ethnicity:
1. Hispanic/Latino
Race:
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
11
(Highest Grade Completed – Non-high School Graduate)
14
12
(High School Graduate)
15
Associate Degree
-- GED or High School Equivalency 16 Bachelor’s Degree
13 Adult High School Diploma 17 Master’s Degree or Higher
Employment:
Full-Time (FT)
Part-Time (PT) Retired (R)
Unemployed – Not Seeking (UN)
Unemployed – Seeking (US) Inmate
Payment:
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:
Card Number:
Exp. (MM / YY)
Colleague ID Number :
Term:
Post Office Box 309, Jamestown, NC 27282
6. Other
Vocational Diploma
1. Home
6. Other
2. Cell
Number (Code)
Fee: $
Location
Course:
Number (Code)
Title
Date:
Begin End
Number (Code)
Fee: $
Location
Total Payment:
Please check one:
Meeting
Meeting
Check one:
*Check
Money Order
Master Card
Visa
Visa
Discover
AmEx
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
