CLASS TITLE
SECTION NUMBER: TERM:
REGISTRATION FEE: OTHER FEE FEE EXEMPT
SOCIAL SECURITY NUMBER
LAST NAME FIRST NAME MIDDLE NAME
ADDRESS (Check here if new address)
CITY STATE ZIP
COUNTY
(Residence) EMAIL ADDRESS
HOME PHONE ( ) BUSINESS PHONE ( ) CELL PHONE ( )
BIRTH DATE Month Date Year SEX (Check One) Male Female
RACE (Check one) White 1 Black 2 Indian 3 Hispanic 4 Asian 5 Other 6
CHECK ALL OR ANY THAT APPLY: Paid Fireman Volunteer Fireman Human Resources Dev.
Paid EMS Volunteer EMS Other
Name of Squad: Paid Law Enforcement Named in EOP
EMPLOYMENT STATUS (check one): Retired Unemployed -Not Seeking Unemployed - Seeking
Full Time Part Time -# hrs per week
Job Title Employer:
EDUCATIONAL LEVEL (Check one): Completed High School 12 GED Diploma Bachelor’s Degree 16
One-Year Vocational Diploma 14 Associate Degree 15
Master’s Degree or higher 17 OR Highest Grade Completed
High School Last Attended Month/Year last attended
CITIZENSHIP (Check one): U.S. Citizen Permanent Resident Alien Alien Authorized to Work Other
STUDENT SIGNATURE TODAY’S DATE
I hereby agree to release my final grade(s) for this course to the N.C. Dept. of Insurance Fire/Rescue Commission/N.C. Criminal Justice’s
Training &Standards Commission and/or NC Sheriff’s Commission, NC OEMS or sponsoring agency. My signature attests that I am actively
affiliated with the public safety agency listed and that I hold the job classification indicated.
Halifax Community College is an Equal Opportunity/Affirmative Action College and accommodates the needs of individuals with disabilities.
WORKFORCE & ECONOMIC DEVELOPMENT STUDENT REGISTRATION FORM
P. O. Drawer 809 . 100 College Drive . Weldon, North Carolina 27890 www.halifaxcc.edu
Phone: 252 536-7261 Fax: 252 536-2241
Yes
No
Name
State
Beginning/End date:
Telecommunicator/Dispatcher
Detention Officer
Correctional Officer
