Pontotoc Technology Center - Business and Industry Services Enrollment Form
Date of Birth
Please Check the school district in which you live
Please check the highest education level achieved
Less than a High School diploma
High School graduate
Some college, no degree
Technical Diploma/Industry Certification
Cash, Check, Money Order
Purchase Order Number
Employer's Name, Funding Agency, or Self-Pay
Race (Please check all that apply)
American Indian or Alaska Native
Black or African American
Native Hawaiian or other Pacific Islander
Other/Prefer not to answer
Pontotoc Technology Center, in compliance with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990 and Title IX of the Education Amendment of 1972, does not discriminate on the basis of race, ethnicity, religion, national origin, age, gender, disability or veteran status in any of its policies, practices or procedures. These equal opportunity provisions include, but are not limited to admissions, employment, financial aid and student services.
By checking yes,I hereby give Pontotoc Technology Center the absolute right and permission to publish photographic pictures of me, in which I may be included in whole or in part, in advertising, promotional or other lawful purposes whatsoever.
Do you consent to the photo release?
THIS SECTION TO BE COMPLETED BY CHICKASAW NATION EMPLOYEES ONLY
Please check one of the Divisions Below
Division of Administrative Services
Division of Aging
Division of Arts and Humanities
Division of Communications
Division of Education and Training
Division of Facilities and Support
Division of Heritage Preservation
Division of Legal Services
Division of Program Operations
Division of Youth and Family Services
Division of Treasury
Division of Commerce (Chickasaw Enterprises)
Division of of Housing and Tribal Development
Division of Health Systems
Chickasaw Nation Employee Confirmation
I acknowledge that my department will be billed for the class for which I am enrolling. I understand that if I cannot attend, I must give at least twenty-four (24) hours notice or my department will be billed regardless of attendance . By completing the fields below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.
Name of Department
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