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Continuing Education Registration Form
Course Information
Course Title*


Course Section Number
Month the Course begins*
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 

E-Mail
Important: Enter a valid e-mail address. Correspondence will be sent to this address.
E-Mail:*

Registrant Information
First Name:*

Middle Initial:

Last Name:*

Address Line 1:*

Address Line 2:

City:*

State:*

Zip Code:*

County

Home Phone:*

Work Phone:

Cell Phone:*

Are you a returning student?*
Yes No 

Students must be at least 16 years old to take these courses through PCC. No exceptions. This is a NC law.
If you are 16 or 17 years old, please contact our office for an additional form that your parents must complete.
Date of Birth*

Day*

Year*

Social Security Number*

Sex*
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*
1
2
3
4
5
6
7
8
9
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. I understand that having any unpaid balances with Piedmont Community College may affect my enrollment in this class. Once your registration is complete you will be contacted with payment information.
Signature:*

Enter first & last name
Date*

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