Issue link: http://digital.pvcc.edu/i/343805
56 PVCC DIGITAL FALL 2014 Workforce Services Class Schedule email@example.com l www.pvcc.edu/workforceservices or 434.961.5354 Name: _______________________________________________________________ Date of Birth: _________________ LAST FIRST MIDDLE Address: ______________________________________ Apt.#: ___________ Day Phone: _________________________ City/County: __________________________State: __________________ Zip Code: ________ County: _________________ Social Security #: ___________________ Email Address: ____________________________________________________ If you have a VCCS EMPL ID, please provide it: ___________Would you like an email confirmation of registration? Yes No Have you ever applied to any Virginia Community College? Yes No __________________________________________________ May we contact you by email about future classes? Yes No Hispanic/Latino Black/African American Asian American Indian/Alaska Native Native Hawaiian/Other Pacific Islander White I choose not to specify NOTICE: IN COMPLIANCE WITH THE SEX OFFENDER AND CRIMES AGAINST MINORS REGISTRY, A PORTION OF THIS INFORMATION WILL BE SUBMITTED TO THE VIRGINIA STATE POLICE. Are you a U.S. Citizen? Yes No If no, your country of citizenship? ______________________________________________ Permanent Status: Resident alien Asylee Refugee A# _____________________________________________________ What is your current immigration status with the U.S.? Not in U.S. – I am requesting visa status. Currently in U.S. I have never served in the U.S. Military I am the dependent of someone who has served in the U.S. Military My spouse has served in the U.S. Military I have served in the U.S. Military _________________________________ What is your current military status? What date did you enter the military? C l a s s N o . D a t e C o u r s e Ti t l e F e e TOTA L $ Method of payment: Check Money Order Credit Card (Call 434.961.5354 to make payment.) Bill employer (Attach purchase order or authorization to bill.) There is a $35 service charge for handling returned checks or dishonored credit card or debit card payments ($50 service charge if your account is in past- due collection status). FAX: Fax registration form to 434.961.5270. DO NOT INCLUDE YOUR CREDIT CARD INFO. Call 434.961.5354 to make payment. Visa/MC/Amex. OR MAIL TO: Piedmont Virginia Community College ATTN: Workforce Services 501 College Dr., Charlottesville, VA 22902 Registration Form for Noncredit Classes (Workforce Services courses only.) P L E A S E P R I N T All books and materials are included in the cost of the class unless otherwise noted. Cancellations - Workforce Services reserves the right to cancel any course. Refunds - Participants must withdraw from a class at least (5) business days before that class is scheduled to begin to receive a full refund. No refunds will be provided after this time. However, you may send another participant in your place. (PVCC ID number must be provided to us.) Refund requests must be made in writing by mail, fax or email (include your name, PVCC ID number, course title, and reason for refund). Refunds are processed by the State Treasury in Richmond and may take 3-6 weeks to process. PAYMENT MUST BE RECEIVED AT TIME OF REGISTRATION. EARLY REGISTRATION IS STRONGLY ENCOURAGED TO GUARANTEE YOUR SEAT. C l a s s s i z e s a r e l i m i t e d a n d r e g i s t r a t i o n i s o n a F I R S T- PA I D, F I R S T- S E R V E D b a s i s . PVCC Workforce Services How to Register MAIL: Complete the form below and mail it with your check, money order (payable to PVCC) or credit card information to: Piedmont Virginia Community College WORKFORCE SERVICES 501 College Dr., Charlottesville, VA 22902 IN PERSON: Bring your registration form and payment to Workforce Services in the Stultz Center. FAX: Fax registration form to 434.961.5270. DO NOT INCLUDE YOUR CREDIT CARD INFO. Call 434.961.5354 to make payment. Visa/MC/Amex. EMAIL: Email us at firstname.lastname@example.org. DO NOT INCLUDE YOUR CREDIT CARD INFO. Call 434.961.5354 to make payment. Visa/MC/Amex. PHONE: Call 434.961.5354 Nondiscrimination Policy Piedmont Virginia Community College does not discriminate on the basis of race, color, religion, national origin, political affiliation, disability, veteran status, sex, age or sexual orientation in its programs and activities. The following person has been designated to handle inquiries regarding the nondiscrimination policies: Human Resources Manager, 501 College Dr., Main Building, Room M810, Charlottesville, VA 22902; 434.961.6567.