WILLIAMSBURG TECHNICAL COLLEGE
Distance Education Application
601Martin Luther King, Jr. Avenue, Kingstree, SC 29556-4103
843-355-4182
www.wiltech.edu
Name:
Last First Middle I. or Maiden Suffix
Mailing Address:
Street Name/Number/PO Box
City State Zip County of Legal Residence
Permanent/Home Phone Business Phone Cell Phone
E-mail address: ID/SS Number Birthdate
The following information is requested for federal & state reporting only:
Ethnic Identification (check one):
Hispanic/Latino
If you did not select Hispanic/Latino, please select one of the following:
American Indian/Alaska Native White
Native Hawaiian/Pacific Islander Black/African American
Asian Two or more races
Gender Male Female
Declaration of Citizenship or Legal Presence in the United States: The South Carolina Illegal Immigration Reform Act (SC Code Ann.
§59-101-430) prohibits those unlawfully present in the United states from attending Williamsburg Technical College or any other
public institution of higher education in South Carolina and from receiving a public higher education benefit. By signing below, you
attest that you are a US citizen, a legal permanent resident in the United States, or an alien lawfully present in the United States. In
addition, Williamsburg Technical College may require that you submit documentation that supports your claim. Any student providing
false information may be subject to dismissal from the college. Any student who is found to be unlawfully present in the United
States will be dismissed from the college.
Print Name Today’s Date
Signature SCDL or ID#
Statement of Terms and Non-discriminatory Policy: Distance Education courses may be cancelled if insufficient enrollment
warrants. If a Distance Education course is cancelled by the college, course fees will be refunded in full. If the course is taught and
one decides to drop, withdraw, or not attend, normally no refund is given. Students under the age of 16 years may take distance
education courses with the written permission of the parent/guardian. Some courses are not available to minors due to SC laws
and/or discretion of the instructor. Senior citizens pay the same advertised course fee as all others.
The language in this document does not create an employment contract between the employee and agency. This document does
not create any contractual rights or entitlements. The agency reserves the right to revise the contents of this document, in whole or in
part. No promises or assurances, whether written or oral, which are contrary to or inconsistent with the terms of this statement
create any contract of employment.
Williamsburg Technical College does not discriminate in its admissions practices, educational programs, activities or employment
on the basis of sex, age, disability, race, color, national origin, or religion.
For office use only – do not write below this line
Course Bill to
Start date End Date Class time
Location - Bldg Room Instructor
Fee $ Received by Date
11.13
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