Public Safety Continuing Education Registration Form

This Public Safety registration form is for affiliated members who are tuition exempt. For all others, please use the Adobe Acrobat Public Safety Registration form for course registration and payment.

Last Name		First Name Middle Initial
Address		City State Zip
County of Residence		Date of Birth
Home Phone		Business Phone (include ext.) Cell Phone
Email		Name of Public Safety Agency
College ID#		Agency Position or Job Title

Gender Male Female	EMS P# (if applicable):	Social Security Number ***SSN required for state fire certification records only

Ethnic Group (Check one) Asian American Indian/Alaska Native Black/African American Hispanic/Latino Native Hawaiian/Other Pacific Islander White Two or more races		Employment Status E4 – Employed 40 or more hours FT – Full Time (40 or more hours/week) PT – Part Time (39 hours or less/week) R – Retired UN – Unemployed (not seeking) US – Unemployed ( seeking)	Highest Education Level Completed (Check one) Non-graduate Highest grade completed GED (12) High School Diploma (13) Adult High School (14) Vocational Diploma (15) Associate Degree (16) Bachelor Degree (17) Master Degree or Higher
First Course: Are you an affiliated member and therefore exempt from tuition? Yes No (please fill in tuition amount even if fee exempt)
Course Number Course Title Location Start Date Tuition Amount
Second Course:
Course Number Course Title Location Start Date Tuition Amount
Third Course:
Course Number Course Title Location Start Date Tuition Amount

By checking this box, I certify I am 18 years or older and not enrolled in high school (a release form from your high school is required otherwise) and also authorize DTCC to release my grades to my employment agency or the credentialing agency as needed for certification purposes only.
After the "Send" button is selected, your browser will display a summary of the form information so it can be saved or printed out for your records.

ACADEMICS

ADMISSIONS

STUDENT SERVICES

Durham Technical Community College
1637 Lawson Street
Durham, NC 27703
(919) 686-3300