Fillable LCCC PUBLIC SAFETY TRAINING INSTITUTE REGISTRATION FORM (Luzerne County Community College)

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LCCC PUBLIC SAFETY TRAINING INSTITUTE REGISTRATION FORM (Luzerne County Community College)

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U.S.A. forms for Luzerne County Community College

BROWSE LUZERNE COUNTY COMMUNITY COLLEGE FORMS

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Name_________________________________________
Department/Co._________________________________
Address_______________________________________
Home Address__________________________________
County of Residence _____________________________
City__________________________________________
State________________________ Zip______________
E-mail Address_________________________________
Soc. Sec. No.___________________________________
Date of Birth____________________________________
Signature_______________________________________
I am paying by: ❑ VISA ❑ Mastercard ❑ Discover
Cardholder's Name:_______________________________
Card Number: Exp. Date:______________________
Signature_______________________________________
Phone Number (Day/Cell)
( )____________________
Phone Number (Night)
( )____________________
Department Phone (extension)
( )____________________
CASH
________________
CHECK NO.
_________________
y
PROGRAM
LOCATION
DAY TIME COST
Please ll out completely. Missing information may delay your registration from being processed. Do not mail cash with this registration form.
The following information is required for state and federal statistical purposes only. Responses will not be used to determine admission.
Gender: ❑ Male ❑ Female
Ethnicity: ❑ Hispanic or Latino ❑ Not Hispanic or Latino
Race: ❑ American Indian or Alaska Native
❑ Asian ❑ Black or African American
❑ Native Hawaiian or Other Pacic Islander ❑ White
Are you a citizen of the United States? ❑ Yes ❑ No (If no, please complete
the following): 1. Country of citizenship: ______________________________________
2. Permanent Resident Card #: ______________________________________________
3. Foreign Student (F1 Student Visa #): _______________________________________
4. Other Visa (type and #): __________________________________________________
Please Check Appropriate Boxes:
❑ Fireghter ❑ Paramedic ❑ EMT ❑ Law Enforcement
Other:___________________________________________
• Complete and return with check(s) or money order(s) for each seminar payable to: LCCC Public Safety Training Institute •
LCCC F-65C
LCCC • PUBLIC SAFETY TRAINING INSTITUTE • REGISTRATION FORM
1333 South Prospect Street, Nanticoke, PA 18634-3899 • Telephone: 570-740-0637 or 1-800-377-LCCC (ext. 7637)
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LCCC PUBLIC SAFETY TRAINING INSTITUTE REGISTRATION FORM (Luzerne County Community College)

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Completed 26 July 2020

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