Workforce/Professional Development Online Registration Form

You must have a credit card to register online (unless the class is free, or fee is waived).  If you wish to pay for your class by cash or check, please print the (PDF) registration form available here, fill it out and either bring it to Hildebrand Hall, Main Campus on Tuesdays between the hours of 8:30 a.m. and 6:00 p.m. or you can mail the registration form and check to WPCC, Business Office/WPD Registration, 1001 Burkemont Ave., Morganton, NC 28655.  The registration form and payment must be received and processed by WPCC at least two business days/48 business hours prior to the start date of the class.

* Required information


Information in this area is for record keeping purposes only and will not be used in a discriminatory manner.  However, this information is required for federal reports, state reports and state certification.  After registering for your class, this information will be destroyed. The Social Security Number is required for federal & state reports, and certification classes.

*Full Name:  
*Social Security Number   (Type numbers only; no spaces or hypens)
Email Address:
*Gender:  Female  Male
*Ethnic Race:  

Credit Card Information

Credit Card Type: Visa  Mastercard
Card Number:
 *3 digit Security Code:   (If taking a fee exempt course, you must enter 000.)
Name as it appears on Card:
Expiration Date: (Month/Year Example: 06/08)

The following information is required by the N.C. Community College System

Datatel ID (If Known):
*Last Name:  
*First Name:  
Middle Name:  
*Mailing Address:  
*City:  
*State:   (If State is not NC, please type in correct 2 digit State code)
*Zip Code:   
*County of Residence:  
*Primary Contact Phone:   Cell Home  (Include area code. Ex: 828-123-5555)
Work Phone:   (Include area code. Ex: 828-123-5555)
*Date Of Birth:   (Example: 04/07/1985)
*Employment Status:  
*Highest Level of Education Completed:  
Select degree/diploma, if received: High School Graduate   GED Diploma   Adult High School Diploma
Vocational Diploma Associate Degree   Bachelor’s   Master’s or Higher
*Date Last Attended High School   (Example: 06/01/1985)
Citizenship:


Listing Agency and Job Title are not required unless you are registering for a class related to your Fire, Rescue, EMS, or Law Enforcement Agency and your fees are exempt.

If Fees Exempt, List Agency (i.e., Fire Department, Law Enforcement, EMS, Rescue)   Volunteer   Paid

Job Title:
 

Certification of Accuracy

 Yes  No

By choosing "Yes", I certify to the best of my knowledge that the information given is true and complete. Further, I understand that by submitting this information via electronic transmission that I acknowledge the above statement of certification in lieu of a signature and grant permission to release appropriate course information to certifying agencies.


*List Course Title(s): Class Beginning Date: Class Time: Office Use:
(Ex. Floral Design, Entrepreneurship) (Ex. 03/05/09 or Mar. 5, 2009) (Ex. 5:00 PM, 11:30 AM)  

© 2008 Western Piedmont Community College. All Rights Reserved.