redit Registration Form
8100 Bob Williams Parkway • Covington • GA • 30014
PH: 404-297-9522 ext. 5046 • firstname.lastname@example.org
Date of Course Course Name
Student Last Name First Name
Phone E-Mail Okey Number
Agency Name Agency Address City State Zip Code
Agency Training Officer Name Phone Email
Send completed form to Karen Carter at email@example.com
or call 404-297-9522 ext. 5046 for more information
Payment Method (choose method and fill out completely);
Electronic Payment (Other than Credit Card)?
Purchase Order (PO) PO Number
*We use Telecheck. Please put your drivers license #, home address, home and work numbers on your Check if it
is a personal check. Make checks payable to Georgia Piedmont Technical College. Address envelope to ATTN; Law Enforcement
Money Order Money Order #
VISA Credit Card Number Exp. Date
Master Card Name of Cardholder
Discover Billing Address of Cardholder
*Signature of Cardholder____________________________________________________________
Payment Contact Info; Name Phone # Email
As set forth in its student catalog, Georgia Piedmont Technical College does not discriminate on the basis of race, color, creed, national or ethnic
origin, sex, religion, disability, age, political affiliation or belief, genetic information, veteran status, or citizenship status (except in those special
circumstances permitted or mandated by law). The following person(s) has been designated to handle inquiries regarding the non-discrimination
policies: Candice Buckley, the ADA Coordinator, at 404/297-9522, ext. 1111, ADA504Coordinator@gptc.edu
or at the main DeKalb campus, 495 N.
Indian Creek Drive, Clarkston, GA 30021 Room A-103B; or Sadie Washington, the Title IX Coordinator, at 404/297-9522, ext. 1210,
TitleIXCoordinator@gptc.edu or at the main DeKalb campus, 495 N. Indian Creek Drive, Clarkston, GA 30021 Room A-157 for assistance.
*PLEASE SIGN AND DATE BELOW – I acknowledge that entering my name on this form is the equivalent of signing it
and by submitting it, I authorize the Registrar to process my payment request.
*Student’s Signature _________________________________________________ Date ______________________________