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Continuing Education Registration Form
Course Information
*Course title(s)One form for multiple classes.
Month the first 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:
County (NC residents only)
*Zip Code:
*Home Phone:
Work Phone:
Cell Phone:
*Are you a returning student? Please state Yes or 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:
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:
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.
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.
*Signature:
*Date
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