Public Safety Registration Form
Please Print
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First Name
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MI
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Last Name
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Nicolet Student ID # or Social Security #
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Home Mailing Address
Office Use Only
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City
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State
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Zip Code
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Phone - Home
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Phone: Cell Work
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County of Residence
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Township/Village/City of Residence
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Date of Birth
Email Address(Required for receiving certificate of completion)__________________________________________________________________Gender: Male Female
Ethnicity: Are you Hispanic or Latino (regardless of race)? Yes No
Race: (Check all that apply) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White
Name of Last High School Attended __________________________________________________________ City/State ____________________________________________
Highest Grade Completed ________ Year of High School Graduation/GED/HSED _______________
Highest Credential Earned: No Credential GED HSED HS Diploma Some college (postsecondary credit) Short-term diploma 1-year diploma
2-year diploma Associate degree Associate Degree + additional credential Baccalaureate Higher than baccalaureate
Class Section Dates Days Time City Building/Room Fee Sr Fee
FEES ARE DUE WITH REGISTRATION
* Senior Fees for person age 62+ are available for Continuing Education classes only
Total Fee:
PAYMENT METHOD Check/Money Order (Payable to Nicolet College) MasterCard Visa Discover
If participant is under age 18, please sign below.
Must be signed by parent or legal guardian.
I give permission for my son/daughter to enroll in
the above class(es) at Nicolet College.
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Signature Date
Card Account Number _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _ Expiration Date: _ _ / _ _
Verification Code: _________ (from signature line on back of credit card)
MAIL TO:
Nicolet College
Attn: Public Safety
PO Box 518
Rhinelander, WI 54501
publicsafety@nicoletcollege.edu
For More Information Call: 715.365.4600 or 800.544.3039 ext. 4600
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Completed Registration Forms may be emailed to publicsafety@nicoletcollege.edu
Law Enforcement Agency ________________________________________________________________
THE FOLLOWING INFORMATION IS FOR STATE REPORTING PURPOSES. INFORMATION PROVIDED WILL NOT AFFECT COURSE ADMISSION.
Billing Address of Card (if different from above):
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