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Technical & Manufacturing Programs
Course Information
Course Title*  
Month the Course Begins*  
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 

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Registrant Information
First Name:*  
Middle Initial:  
Last Name:*  
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Address Line 2:  
City:*  
State:*  
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Zip Code:*  
Home Phone:*  
Cell Phone:*  
Sex*  
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Date of Birth*  
  
  
SSN*  
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?*  
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Ethnic Origin:*  
Educational Experience*
Highest Educational Level Completed*  
Employment Status*
  
Employed Full Time Employed Part Time Retired Unemployed-Not seeking Unemployed-Seeking employment 

Electronic Signature
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.
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Date*  
Photography & Quote Release: I hereby authorize Piedmont Community College to use my image and/or quotes for any use the College deems appropriate in the promotion and marketing of PCC.
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