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HIGH SCHOOL EQUIVALENCY PROGRAM REGISTRATION
COLLEGE AND CAREER READINESS
PIEDMONT COMMUNITY COLLEGE
COURSE SELECTION
Program of Interest*
Choose One of the Following:
Adult High School (16-18 year olds only)
AEMT/EMT Program TABE Test Prep
HS Equivalency Program and Orientation
Build your Skills
Choose a Program
Adult Basic Skills (Math, Reading, Writing)
Career Launch Services
Computer Basic Skills/Digital Literacy
English as a Second Language (ESL)
Explore Industry-Recognized Certifications
STUDENT INFORMATION
First Name*
Last Name*
Middle Initial
E-Mail Address*
Mailing Address*
City*
State*
Choose a State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
ZIP Code*
County (NC Only)*
Choose a County
N/A
Alamance
Alexander
Alleghany
Anson
Ashe
Avery
Beaufort
Bertie
Bladen
Brunswick
Buncombe
Burke
Cabarrus
Caldwell
Camden
Carteret
Caswell
Catawba
Chatham
Cherokee
Chowan
Clay
Cleveland
Columbus
Craven
Cumberland
Currituck
Dare
Davidson
Davie
Duplin
Durham
Edgecombe
Forsyth
Franklin
Gaston
Gates
Graham
Granville
Greene
Guilford
Halifax
Harnett
Haywood
Henderson
Hertford
Hoke
Hyde
Iredell
Jackson
Johnston
Jones
Lee
Lenoir
Lincoln
Macon
Madison
Martin
McDowell
Mecklenburg
Mitchell
Montgomery
Moore
Nash
New Hanover
Northampton
Onslow
Orange
Pamlico
Pasquotank
Pender
Perquimans
Person
Pitt
Polk
Randolph
Richmond
Robeson
Rockingham
Rowan
Rutherford
Sampson
Scotland
Stanly
Stokes
Surry
Swain
Transylvania
Tyrrell
Union
Vance
Wake
Warren
Washington
Watauga
Wayne
Wilkes
Wilson
Yadkin
Yancey
Home Phone*
Cell Phone
SSN*
Birth Month*
Choose Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day*
Choose Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Year*
Choose Year
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Last Grade Completed*
Choose one of the Following
1
2
3
4
5
6
7
8
9
10
11
12 (No Diploma)
12 (Graduated with Diploma)
Vocational/Certification (1-year)
Associate`s Degree (2-year)
Bachelor`s Degree (4-year)
Master`s Degree and Higher
Employment Status*
Choose one of the Following
Full Time
Part Time
Not Employed-Not Seeking
Not Employed-Seeking
Ethnicity*
Choose One
Hispanic/Latino
Non-Hispanic/Non-Latino
Race*
Choose one of the Following
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White or Caucasian
Are you a Returning Student at PCC?*
Choose one of the Following
No
Yes
Gender*
Choose a Gender
Female
Male
DISCLAIMER
Age Requirement Notice
By North Carolina law, students must be at least 16 years of age to enroll in courses offered through Piedmont Community College. No exceptions are permitted. Students who are 16 or 17 years old must contact our office to obtain and submit an additional form requiring a parent or legal guardian`s signature.
Disclosure of Demographic Information
Piedmont Community College is often asked to provide general statistics about the racial and ethnic makeup of our student body and employees. Your response will not affect your admission or enrollment. All information collected is protected personal information and is not shared externally without explicit permission. PCC abides by strict FERPA Laws.
ELECTRONIC SIGNATURE
SIGNATURE*
DATE*
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