To receive a refund, a student must submit
a refund request in writing at least 10 days
prior to the start of the class. No refunds
will be issued after that period
.
FAX or Mail this form to:
321-433-7525
Workforce Training
1519 Clearlake Rd, 25-111
Coco, FL 32922
Eastern Florida State College
NON-CREDIT REGISTRATION
SS# or Student B# Birthdate: Sex M □ F
Student B#: go to www.easternflorida.edu go to EFSC Logins (green top right corner), Drop down menu select “My EFSC”. Click on “Look up
your student ID”.
Last Name First Name Middle/Maiden
Street Address
City/State Zip Home Phone
E-mail Address: Cell or Work Phone
Any applicant with a disability who requires assistance or reasonable accommodations may contact the Office for Students with Disabilities at
the following locations: Cocoa Campus – 433-7295 Melbourne Campus – 433-5650 Palm Bay Campus – 433-5172 Titusville Campus – 433-
5017 Hearing Impaired – 1-800-747-2802 (Voice)
COURSE INFORMATION : NEW SHRM CP/SCP
CRN # COURSE TITLE DAY TIME CAMPUS BLDG ROOM FEE START DATE
SAMX 0059 SHRM CP-SCP
Test Prep, Learning System
Thurs. 6-9 pm C 25 116 $1069 2/18/2016
SHRM Member Discount Member #______________
$969
Early Registration Discount Prior to Jan. 28 $969
TOTAL
________________________________________________________________________ __________________________
SIGNATURE OF APPLICANT (sign in ink) DATE
Fall
Spring
Summer
The following information is requested for statistical purposes and to report in compliance with State and Federal regulations.
High School Diploma Ethnic Origin:
❒ Yes Are you Hispanic or Latino?
❒ No ❒ Yes ❒ No
Veteran Code Race Origin(Choose one or more):
❒ Not Applicable ❒ American Indian or Alaskan Native ❒ Asian
❒ Veteran ❒ Black or African American ❒ White
❒ Native Hawaiian or Other Pacific Islander
ARE YOU A U.S. CITIZEN? ❒ Yes ❒ No
If no, please indicate Residency status below:
❒ Permanent Resident Alien (P) ❒ Non-Resident Alien (A)
STUDENT CERTIFICATION: I declare under penalty of perjury punishable by law as a misdemeanor under
Section 837.06, Florida Statutes, that the foregoing is true and correct. I will not engage in the unlawful
manufacture, distribution, dispensation, possession, or use of a controlled substance during enrollment at
Brevard Community College according to the College’s Drug-Free Policy. I agree to abide by all regulations
of the College and the laws of the State of Florida.
CREDIT CARD AUTHORIZATION FORM
If paying by credit card, please fill out the following information: Name of credit card holder:
Amount: $ Visa M/C Discover American Express
Credit Card # Exp Date
Billing address: City/State: Zip Code:
I authorize Eastern Florida State College to charge my credit card for the above amount:
*“In compliance with Florida statute 119-07(1): SSN is requested for the sole purpose of registering non credit, continuing education students.
SSN’s are confidential, are immediately converted to student ID or “B” numbers to insure confidentiality and may be used for no other purpose.
SSN’s may only be disclosed to another agency or governmental entity if necessary for the receiving agency or entity to perform its duties and
responsibilities as authorized by law.”
OC-47 R1107
click to sign
signature
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