Workforce Solutions
Continuing Education
Registration Form
*Last Name *First Name *Middle Initial *Maiden Name
*Mailing Address *City *State *Zip Code *County
*Home Phone Number *Work/Cell Phone Number *Gender (Check One) *Date of Birth (mm/dd/yyyy)
Male   Female
E-mail Address Employer
Voluntary Information
(check one)
Asian or Pacific Islander (O)
American Indian (I)
White (I)
Black, Non-Hispanic (B)
Hispanic (H)
Other (X)
When Workforce Solutions Continuing Education classes are cancelled, course fees will be refunded. Confirmed registrants who do not attend class, or who cancel less than 10 business days before the first class meeting, are responsible for the entire registration fee. There is no refund for one-day workshops and seminars.

Please note: Class participation will be documented on your Northeast State Community College transcript.
*Course Title *Start Date Day Time *Fee
Registration Sample Course 07-01-07 R 6 p.m. - 9 p.m. $ 95.00
  Total Due: $
I certify that all statements on this application are correct and complete.
Signature Date

Payment is due at the time of registration. Course fees are payable by credit card (MasterCard, Visa, Discover, and American Express), cash, money order, or company purchase order. Make checks payable to Northeast State or pay by credit card using the Pay Tuition/Fees tab on the Northeast State website.

Mail to: Northeast State
Attn: Diana Harrison
P.O. Box 246
Blountville, TN 37617
or Fax: 423.323.0220
Telephone: 423.354.5520
For office use only:  Date received ________  Date paid ________  Amount paid ________  Initials ________
NSTCC-3 08-008