Seminar Pre-Registration Form


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

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: October 06, 2009