Seminar Pre-Registration Form (You are strongly encouraged to reserve your place for each seminar.  This will ensure there are enough participants to conduct the seminar and that adequate seating is available.)


Please complete the following form to pre-register for any of our seminars.  If you have any questions, feel free to contact us at 910-592-7176 ext 2032.

Seminar/Workshop Title:

Note: If desired, you may hold down the Control Key (Windows) or the Apple Key (Macintosh) while clicking your mouse button to select multiple seminars from the list above.

Contact Information:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail

Date of Birth and Sex:

Date of Birth
Sex Male Female

Race:


Choose Highest Grade Completed:


North Carolina Resident?

Yes 
No

Name of state if non-resident:

County of Residence: (If you are a non-resident of North Carolina, choose Other)


Employment Status:

Full-Time (F)
Part-Time (P)
Retired (1)
Unemployed, not-seeking (2)
Unemployed, seeking (3)

Place of Employment:

Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Handicapped/Disabled?

Yes
No

Are you on our mailing list?

Yes
No

If no, would you like to be added to our mailing list?

Yes
No

By choosing I Agree below, I am certifying that I have completed the above registration form for the seminar chosen.  I further certify that the information is accurate and complete.

I Agree
I Do Not Agree

Date :

-- mm/dd/yy


Sampson Community College Small Business Center.
Revised: January 06, 2011