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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 Address        Name of Public Safety Agency    
College ID#        Agency Position or Job Title    

Gender
Male
Female

EMS P# (if applicable):
  
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:  
Course Number      Course Title    Location     Start Date  

Second Course:
 
Course Number      Course Title   Location     Start Date  

Third Course:
 
Course Number      Course Title   Location     Start Date  
     
     

 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. You will also receive an automated response once your registration form is received.

   

 




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

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