TRAINING PROGRAMS
REGISTRATION FORM
INDIVIDUAL REGISTRATION/PAYMENT
Please register me for the following course(s): (Example: CEBEG 517 21 Intro to Computers Sep 1-2 NEAST $129)
Course: Title: Date: Location: Price:
Course: Title: Date: Location: Price:
Course: Title: Date: Location: Price:
Course: Title: Date: Location: Price:
Name:
First MI Last
SSN: DOB:
Email address for notifications: Drivers License #: State:
Driver’s license # and state required to verify lawful presence
Home Address:
Street City State Zip Code
Phone # for notifications:
Day Night Cell
Gender*: ¨ Male ¨ Female Race*: ¨ Asian ¨ Black/African American ¨ White
Ethnicity*: ¨ Hispanic/Latino ¨ Non-Hispanic/Non-Latino
¨ American Indian/Alaskan Native ¨ Hawaiian/Pacific Islander
*Voluntary information used for institutional effectiveness reporting.
Check Enclosed for: $ Check #:
Card type: ¨ ¨ ¨ ¨ Card Number: Expiration:
A 2.5% credit card service fee will be applied to all credit and debit card transactions used to pay tuition and fees.
Card Identification Number (3 digits on back of card):
Name as listed on credit card: Signature:
COMPANY REGISTRATION/BILLING
Company Registration/Billing may be handled three ways:
1. By letter of authorization on company letterhead with the company’s address, phone number, and point of
contact information along with the statement of authorization to bill
2. By purchase order
3. By company check or company credit card
Each request to register and bill must include the personal information listed above along with either a letter of
authorization, purchase order, check, or credit card information.
For information or to register by phone, please call our registration office at 803.732.0432,
or you can register online with a credit card at MIDLANDSTECH.EDU/schools.
RETURN COMPLETED FORM
Email: CCE@midlandstech.edu | Call: 803.732.0432 | Fax: 803.732.5255
Stop by one of our registration locations or mail to
Midlands Technical College, Corporate and Continuing Education, PO Box 2408, Columbia, SC 29202
CC-19-5881-03-20
click to sign
signature
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