Central Carolina Technical College does not discriminate in employment or admissions on the basis of race, color, national origin, sex, gender identity, sexual orientation,
genetic information, age, religion, pregnancy, childbirth, or related medical conditions, including but not limited to, lactation, disability, or any other protected class.
Wo
rkforce Development & SC Environmental Training Center
REGISTRATION FORM
4 w
ays to register:
Mail: Central Carolina Technical College Workforce Development: 506 N. Guignard Dr., Sumter, 29150
Hand Deliver: CCTC’s AMTTC at 853 Broad St., Sumter
Email: etc@cctech.edu
Fax: 803-774-6995 Questions: 803-778-6656
Na
me: ______________________________________________________________________________________________
Course Name: ________________________________________ Course Date: ________________ Course Cost: _________
Online: Yes No Short School Level (Choose One): A B C D E (Water & Wastewater Only)
Date of Birth: ____________________ Last 4 Digits of Social Security: ________________ Gender: Male Female
(Required)
(Requested)
US Citizen: Yes No Ethnicity: African American American Indian Asian Hispanic White
Address: ____________________________________________________________________________________________
(Street)
(City) (C
ounty)
(
State) (Zip)
Work Phone: ___________________ Cell Phone: ___________________ Service Provider Name: ____________________
I authorize CCTC to text me about registration, billing or scheduling issues. Yes No Text message rates may apply.
Company Name: _______________________________________ Email: _________________________________________
PAYMENT INFORMATION:
CHECK (Payable to: Central Carolina Technical College) CREDIT CARD (Choose One) VISA MC AE
I, ________________________________________________ hereby authorize CCTC to charge the credit card listed below according to
the terms outlined above. This payment authorization is for the training/services described above, for the amount indicated above
only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment
with the credit card company; so long as the transaction corresponds to the terms indicated in this form.
REFUND POLICY: A full refund will be issued for all courses, seminars, and workshops canceled by Central Carolina Technical College.
Registrations canceled before the cutoff date, ten (10) working days before the scheduled training, will be assessed a 20%
administrative fee. There will be no refund for a cancellation less than ten (10) working days prior to the start date. Refunds may be
requested by mail, email, in person, or by telephone. These requests are the responsibility of the registrant.
Confirmation or receipt available upon request. Call 803-778-6656 or email etc@cctech.edu
Name on Card: ____________________________________ Credit Card #: _______________________________________
Card Billing Address: _____________________________________________ Card Exp.: _______ Security Code: ________
