Application for Workforce, Community, and Continuing Education Course Registration FormDate* Date Format: MM slash DD slash YYYY Course Name*Location* Contact InformationName* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country U.S. Citzen*YesNoIf No, List Country of Residency*Social Security Number*Date of Birth* Date Format: MM slash DD slash YYYY GenderMaleFemaleHome Phone NumberWork Phone NumberCell Phone NumberEmail* Demographic InformationEthnicity*HispanicNon-HispanicRace*WhiteAfrican AmericanAmerican Indian / Alaskan NativeNative Hawaiian / Pacific IslanderTwo or more racesAre you a military veteran?YesNoHave you ever been convicted of a felony?YesNo Education Information (Optional)Secondary EducationHigh School GraduateGEDHigh School StudentHigh School/GED Institution AttendedGraduation Date Date Format: MM slash DD slash YYYY Post Secondary Education Student/Applicant Declaration & Signature By Signing below, I declare that the information I have supplied on the application/registration form is complete, truthful, and correct. By signing below, I further authorize New River Community and Technical College personnel to verify the information stated on this document.I give my permission for videos and/or photos to be taken of me for use in publications, newspapers, TV, website, or other visual media to promote educational programs and/or student activities at New River Community and Technical College. This release shall apply to the use of my voice, name, likeness, and facts relating to me as well as my oral statements. I understand that images and recording made for this purpose are the property of New River Community and Technical College. I hereby waive any right that I may have to inspect and approve the finished product or the copy that may be used in connection herewith. I warrant and represent that I am over the age of eighteen (18) years and that I am free to enter into this agreement.*NoYesFull Name (Signature)*Today's Date* Date Format: MM slash DD slash YYYY By initialing here, I certify that my electronic signature above has all the legal standing of a regular signature.*CAPTCHA Last Updated On: 20th February, 2018