PERSONAL INFORMATION (Fields marked with * are required)
*Last Name: *First Name:
*Middle Name: *Maiden/Previous Name:
*Address:
*City: *State:
*Zip Code:
Telephone: Other Telephone:
*Date of Birth: *Email Address:
Gender: Male            Female Ethnicity:
Supervisor's Name Supervisor's Email
Have you ever taken a course through Randolph CC before?     Yes            No

EDUCATIONAL EXPERIENCE
*Select highest grade completed or choose answer:

EMPLOYMENT STATUS
Vocation:
Employment: Employer:
Name of Fee Exempt Agency: Your Title:

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
When did you move to North Carolina? (M/D/Y)
*Citizenship: U.S. Citizen Eligible Legal Alien Naturalized Non Resident Alien Certification of Accuracy

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 No:
2.  Course Name: Course No:
3.  Course Name: Course No:
4.  Course Name: Course No:
5.  Course Name: Course No:
6.  Course Name: Course No:
7.  Course Name: Course No:
8.  Course Name: Course No:
9.  Course Name: Course No:
10.  Course Name: Course No:
ARE YOU TAKING THIS COURSE TO PREPARE FOR CERTIFICATION OR RECERTIFICATION?     Yes            No
IF YOU ARE FEE EXEMPT FOR THIS COURSE, PLEASE INDICATE REASON FOR EXEMPTION:
If you are fee exempt, you will be contacted by e-mail within 1 week to confirm your registration and provide you with 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: dscallicutt@randolph.edu or call the Emergency Services Training Center at (336) 633-4165.
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 acknowlege the above statement of certification in lieu of a signature.