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:
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:
INDIVIDUAL REGISTRATION/BILLING
REGISTER ONLINE | Register with a credit card at
MIDLANDSTECH.EDU/schools
REGISTER BY PHONE | Call our registration office
at 803.732.0432
REGISTER WITH THIS FORM | Return completed form via
one of the methods below:
> Email: CCE@midlandstech.edu | Fax: 803.732.5255
> S top by one of our registration locations listed at
MIDLANDSTECH.EDU/TrainingStudentResources
> Mail to Midlands T echnical College, Corporate and
Continuing Education, PO Box 2408, Columbia, SC 29202
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.
Refunds may be granted with advanced notification. Details at MIDLANDSTECH.EDU/TrainingStudentResources.
CC-20-6824-10-20
click to sign
signature
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