www.bladencc.edu An Affirmative Action/Equal Opportunity Institution
Section No _________
PO Box 266 Dublin, NC 28332 Telephone 910.879.5568 or 5561 Fax 910.879.5569
COURSE NUMBER
COURSE TITLE
Day
SECTION NO
START DATE
SSN/BCC NO
LAST
FIRST
MI
MAILING ADDRESS
CITY
ZIP
HOME PHONE
CELL
COUNTY
E-MAIL ADDRESS
DATE OF BIRTH
M-
D-
Y-
Female Male
White
Black
Hispanic
Asian
Native American
Other
EDUCATIONAL LEVEL
_____ Non Graduate
(Enter highest grade completed 0-11)
High School Graduate
HSE Diploma
(High School Equivalency)
Adult High School Diploma
Vocational Diploma
Associate Degree
Bachelor’s Degree
Master’s Degree or Higher
HEAD OF HOUSEHOLD
Yes No
Employed
1-10 hours
11-20
21-39
40 or more
Unemployed
Seeking
Not Seeking
Retired
Tuition Fee Waived
Emergency Services Agency
____________
________________________
Paid
Volunteer
Authorized Group or Organization
(job classification)
Firefighter (Vol Agency)
EMS Responder (Vol Agency)
Emergency Mgt. Personnel
Telecommunicator/Dispatcher
Sponsored BLET
DACJJ Certified Officer
(Note:
Student must indicate title for DACJJ;
See appendix in Waver Reference Guide
for eligible Corrections /JJ job titles.)
Firefighter
(County/State/Municipal Agency)
EMS Responder (County/State Municipal Agency)
Named i
n EOP______________________
LE Officer
Detention Officer
Other ____________________________
My signature attests that I am actively affiliated with the public safety agency listed above and that
I hold the job classification indicated.
Student Signature: Date:
TUITION REFUND POLICY
Refunds are allowed under the following circumstances:
A student who officially withdraws, in writing, from an occupational extension class prior to the first class meeting or if a class is cancelled shall be eligible for a 100%
refund.
After class begins, 75% shall be refunded at the request of the student if the student officially withdraws, in writing, from the class prior to or at the 10% point of the
scheduled hours of the class. Note: This rule is applicable regardless of the number of times the class meets or the number of hours the class is scheduled to meet.
For contact hour classes, students must withdraw, in writing, within 10 calendar days.
Registration fees for self-supporting classes are non-refundable once the class begins.
Office Use Only Method of Payment
$
Course Fees
Cash
Credit Card
Check:
$ Total Collected Third Party Billing
Person Receiving Payment Receipt No.
CONTINUING EDUCATION, ECONOMIC & WORKFORCE
DEVELOPMENT REGISTRATION FORM
RGPE
ASPR
XNCA
RGN
ARAI
Eve
Submit Form
click to sign
signature
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