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
Course
Location M
T
W Th
F
Sa Su
Start
End
Start
End
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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