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CONTINUING EDUCATION REGISTRATION FORM
   
Please assist us in serving you by completing the following items. The information will be used only in college reports required by the State of North Carolina and the federal government, in accordance with Federal Education Rights & Privacy Act (FERPA), and to provide an accurate record of courses taken through our institution for future transcript requests.

Date:
PERSONAL INFORMATION * Required Fields
*Last Name:
*First Name:
Middle Name:
Maiden/Previous Name:
*Address:
*City:
*State:
*Zip Code:
*Telephone:
Other Telephone:
*Email Address:
*Gender: Male Female
*Date Of Birth: (Month/Day/Year)
*Ethnic Background:
Have you ever taken a course through DCCC before? Yes No
EDUCATIONAL EXPERIENCE
*Select highest grade completed or choose answer:
EMPLOYMENT STATUS
Vocation
*Employment
Employer:
*RESIDENCY
Do you claim to have been a legal resident of the state of North Carolina for a period of at least twelve months immediately prior to the date of this application? Yes No
If yes, which county?
If no, where are you a legal resident?
When did you move to North Carolina? (Month/Day/Year)
*Citizenship? U.S. Citizen Eligible Legal Alien Naturalized Nonresident Alien
Certification of Accuracy

Please check: By this check I certify that the information I have given is true and complete to the best of my knowledge. I further understand that falsification or failure to supply the correct information may be considered grounds for rejection or dismissal. Further, I understand that by submitting this information via electronic transmission that I acknowledge the above statement of certification in lieu of a signature.
COURSE INFORMATION
This form is for the use of continuing education students only. Students who are enrolled for classes on campus should see their advisor to register. Registrations can only be accepted during the scheduled registration periods.
1.
 Course Name Course CID #
2.
 Course Name Course CID #
3.
 Course Name Course CID #
4.
 Course Name Course CID #
5.
 Course Name Course CID #
6.
 Course Name Course CID #
7.
 Course Name Course CID #
8.
 Course Name Course CID #
9.
 Course Name Course CID #
10. Course Name Course CID #

ARE YOU TAKING THIS COURSE TO PREPARE FOR CERTIFICATION OR RECERTIFICATION?

Yes No
If no, have you taken this course more than twice during the last 5 years? Yes No

IF YOU ARE FEE EXEMPT FOR THIS COURSE, PLEASE INDICATE REASON FOR EXEMPTION:

Other:

If you are fee exempt, you will be contacted by e-mail within 1 week to confirm your registration and provide you with any additional information.  If you are NOT fee exempt, you will be contacted by phone regarding payment options. 

*NOTE:  If you are not fee exempt, your registration will not be effective until you provide us with payment information.  If you have any questions, you may contact us via the following: ceregistration@davidsonccc.edu or phone CE Registration at 336.249.8186.

Davidson Campus  ·  PO Box 1287, Lexington, NC 27293 · 336.249.8186 ·  FAX:  336.248.6714
Davie Campus  · 1205 Salisbury Road, Mocksville, NC 27028 · 336.751.2885  · FAX:  336.751.6192