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Continuing Education Secure Registration Form
Course Information
*Program you are registering for:
Notary Defensive Driving Other 
*Course Title(s)You may abbreviate titles.
Course Title(s)
Month the course begins
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 
Important: Enter a valid e-mail address. Correspondence will be sent to this address.
Registrant Information
*First Name:
Middle Initial:
*Last Name:
*Address Line 1:
Address Line 2:Apt. or Suite No.
County (NC residents only)
*Zip Code:
*Home Phone:
Work Phone:
Cell Phone:
*Date of Birth:
Social Security Number
Male Female 
Colleges and Universities are asked by many, including the federal government, accrediting associations, college guides, newspapers, and your own college/university communities, to describe the racial ethnic backgrounds of our students and employees. In order to respond to these requests, we ask you to answer the following two questions:
Do you consider yourself to be Hispanic/Latino?
Yes No 
Ethnic Origin:
Educational Experience
*Highest Educational Level Completed
10 11 12 High School Graduate GED (General Educational Diploma) Vocational Diploma/Certificate Associate Degree Bachelor`s Degree Master`s Degree or higher 
Employment Status
*Employment Status:
Electronic Signature
The information I have given is accurate to the best of my knowledge.
Optional Credit/Debit Card Payment Information
You may pay for your course using this secure form. Another payment option is to mail it to:
105 North Main Street
Roxboro, NC 27573

***Please note that your card will not be charged immediately upon submission.*** We must take the information provided and have our business office manually enter the charge to obtain approval. You will only be contacted if there is a problem.
Name as it appears on your statement
Is the address in the registration form above, the same as your credit card billing address?
Yes No 
Address as it appears on your statement
Zip Code
Credit card number
*Card Brand:
*Security CodeThe 3 digit number on the back
*Expiration date
*Amount to be charged ( you can pay for more than one course)
Electronic Signature for Credit Card Charge
I hereby authorize Piedmont Community College to charge my credit card for the amount listed above.
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