Pontotoc Technology Center - Business and Industry Services Enrollment Form
Course Name *
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Course Date *
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Course Time *
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Last Name *
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First Name *
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Middle Initial
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Date of Birth *
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E-Mail Address *
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Contact Phone *
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Address *
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City *
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State *
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Zip Code *
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Please Check the school district in which you live *
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Please check the highest education level achieved *
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Payment Method *
Purchase Order Number
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Employer's Name, Funding Agency, or Self-Pay *
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Race (Please check all that apply)
Gender *
Notice
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.
Photo Release
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
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.
Employee Name
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Name of Department
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Job Title
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Initials
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Supervisor Name
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Account Number
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