Public Safety Continuing Education Registration
Complete this form and mail or fax with payment to:
Payment or payment authorization is required at time of registration and
Durham Technical Community College
mustbe received before the first class.
2401 Snow Hill Road, Durham, NC 27712
Receipts or confirmations will not be sent for payments that are faxed or mailed.
Fax: 919-536-7263
The refund policy can be found at
Phone: 919-536-7242 x4601
durhamtech.edu/continuing-education/register-continuing-education
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: ____________________________________ Social Security number:__________________________
Public safety agency:_________________________________ Position or job title:____________________________
Highest education level completed Race (check all that apply) Gender
Non-graduate American/Alaska native Female
(highest grade completed) ____ Asian Male
GED Black/African-American
Employment status
High school diploma Hawaiian/Pacifc Islander
Full time (40 or more hours/week)
Adult high school Hispanic/Latino
Part time (39 or fewer hours/week)
Vocational diploma Non-Hispanic/Non-Latino
Retired
Associate’s degree White
Unemployed (not seeking)
Bachelor’s degree
Unemployed (seeking)
Master’s degree or higher
Course
Number
Course
Title
Location M
T
W Th
F
Sa Su
Start
Time
End
Time
Start
Date
End
Date
Cost
By my signature, I certify I am 18 years or older and not enrolled in high school (a release form from your high school is required
otherwise) and also authorize Durham Tech to release my grades to my employment agency or the credentialing agency as
needed for certifcation purposes only.
Student signature______________________________________________________ Date __________________________
College employee signature _____________________________________________ Date __________________________
$_________ Registration fee paid received from student _________or_____________________________________
$________ Registration fee billed to sponsoring agency _______________________________________________
$_________ Books _____________ Other ______________ Check #:______________ Bank:____________________
Credit card #:____________________________________________AMEX ___ DISCOVER ____ MC____ VISA ____
Cardholder name:_____________________________ Exp. date: __________ (MM/YY) Credit card security #: _____
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signature
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