Student Membership Form

CARTERET COMMUNITY COLLEGE
Corporate & Community Education


Please complete all information below. Your email address will be your member userid. Your initial password will be your home telephone number including area code. For example, if my email address is "doe321@netscape.com" and my home telephone number is "252-351-1234" then my user name would be "doe321@netscape.com" and my password would be "2523511234" (no dashes in the phone number).All fields marked with * are required.
STUDENT INFORMATION
First Name:*
Last Name:*
Social Security Number: - -
E-mail Address:*
Telephone Number (include area code)Home:* () -
Telephone Number (include area code)Work: () -
Street Address:*
City:*
State:*
Zip Code:
Please include your date of birth information below:*
Month of Birth:Day of Birth:Year of Birth:
All students under 18 must complete a dual enrollment form to attend class.
Occupational students over 65-instructor must verify age in order to exempt tuition fee.
Sex: Male Female
Race: White Black Indian Hispanic Asian
Highest Grade Completed: or:(check below)
GED Diploma Adult High School 1 Year Voc Diploma
Associate Degree Bachelor's Degree Masters or higher
Residence: State: County:
Vocation:
Employment: Retired Full-Time Part-Time Unemployed
Employer: