Professional, Technical & Community Education

Personal Information

Course Date	Course Number	Course Title	Fee

Payment Method

Cash/Check

Credit Card , Please call (307) 872-1326 with your card information

Purchase Order # Company

Bill Company Mailing Address

Individuals are personally responsible for payment in the event that the indicated company or organization fails to make payment in full.

I understand that once my registration is processed, I am officially registered for the class and am responsible for all debts incurred. If my account is not paid in full, I understand that the College may hire a collection agency to take action. If my account is assigned to a collection agency, I understand that I am responsible for all attorney fees, court costs or delinquency fees that may be incurred during the collection of my debt. I understand that the delinquency fee will be equal to 50% of the principal amount owed. If a refund is due from my account, I authorize the College to automatically issue a refund check.

Call us early with your ADA needs. 307.382.1806

If you have any questions please feel free to contact us at: ptce@wwcc.wy.edu 307.872.1326

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Name: E-mail:
Address:
Street/P.O. Box: Home Phone: Work Phone: Social Security #:		City State Zip *Age: Sex:* Female Male Birth date:
1. How many years have you lived at the above address? 2. If a Wyoming resident, how many years have you lived in Wyoming?
Do you give WWCC permission to release your name, address, and enrollment status as part of our directory information?Yes No
Ethnicity:
Black Hispanic White	American Indian Asian/Pacific Islander Non-resident Alien
*Required for reporting purposes only.

I am enrolling in this course/activity for the following reasons:
Degree seeking from WWCC Upgrade current job skills Develop new job skills Coursework toward degree from another institution Teacher re-certification (PTSB) DEQ Re-certification (DEQ) Law Enforcement Re-certification (POST)	Build basic skills before taking credit classes Workshop required by employer Physical activity/health Basic skills (ABE, GED, ESOL) Children's programming Personal Enrichment Other (specify)
How did you find out about this class? (FOCUS booklet, flyer, TV, WWCC class schedule, e-mail, web, word of mouth)

Professional, Technical & Community Education

Name:

E-mail:

Address:

Street/P.O. Box:

City

State

Zip

Ethnicity: