Public Safety Registration Form

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This field is for validation purposes and should be left unchanged.

Section 1

Last 4 Digits of SS#*

First Name*

Middle Initial

Last Name*

Date of Birth*

65 years of age or older?

I am a...*

Persons under 16 years of age will NOT be allowed to register.

Section 2

Please continue to Section 3.

Home Address*

City*

State*

Zip*

Country*

Home Phone*

Work Phone

Cell Phone

Email*

Enter Email Confirm Email

Gender

NC Resident

Employment Status*

Race

Ethnicity

Select Highest Grade Completed

Section 3

Note: In order to qualify for a fee exemption, the course for which you are registering must support the training needs of the public safety organization(s) with which you are affiliated and must be directly related to your duties within that organization. If the information below is not completed in its entirety, a fee waiver will NOT be granted and you will be responsible for payment. If a fee waiver is not granted and/or payment is not received in full, you will NOT receive credit for this class.

Job Classification*

Job Classification "Other" - Please Specify*

Organization Name (no abbreviations)*

Course Selection*

Section 4

By typing my full name into the box below, I certify that the information on this application is correct. Also, I agree to abide by the rules, policies and regulations of the college during my enrollment at Tri-County Community College (TCCC). I understand that my registration cannot be processed if I have an outstanding debt with TCCC. Finally, I grant permission to release the appropriate course information to the certifying agency, or, if applicable, to the public safety organization listed in section 3 above.

Full Name*

I agree to the terms of agreement stated above.*

Yes

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First Choice

Second Choice

Third Choice

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