Continuing and Community Education Registration Form

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Name*
First Middle Last
SS ID/ Government ID*
Required to create individual identifier. SSN is NOT kept on file once identifier is created.
Date of Birth*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Home Phone Number
Cell Phone Number
Work Phone Number
Email*
Name of Course*
Beginning Date of Course*
Ethnic Group
- Asian or Pacific Islander
- Black, Non-Hispanic
- Hispanic
- American Indian
- White, Non-Hispanic
Primary Reason For Course
- Maintain Licensure
- Get A Job
- Improve Skills Current Job Skills
- Other
If other, please list.

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