Law Enforcement/Public Safety

CLASS TITLE* Fill in course name
Class Start Date Class End Date
Important: Enter a valid e-mail address. All 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:* Cell Phone:*
Sex* Male Female 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?* Yes No Ethnic Origin:*
Educational Experience
Highest Educational Level Completed*
Employment Status
Employment Status:*
Name of Law Enforcement Department
Department Name Select as Applies:
Name of Supervisor Contact Number for Supervisor
Electronic Signature
I understand that having any unpaid balances wtih Piedmont Community College may affect my enrollment in this class.
Signature:* Enter first & last name Date*

Students enrolling in Public Safety classes must be at least 18 years of age and must provide a Concurrent Enrollment Form each semester he/she is enrolled in a public/private/home school until his 18th birthday. Contact the Continuing Education Office at (336) 694-8052 for the Concurrent Enrollment Form.
Signature:* Enter first & last name 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. I fully discharge PCC from any and all claims, monetary or otherwise, arising out of the image or quote.
Signature: Optional, sign if authorized Date:
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