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Non-Credit Registration Form 96-045 Ala Ike, CE -101

Pearl City, HI 96782


You may fax this form to 808-453-6730 Phone: (808) 455-0477; Fax (808) 453-6730
Office of Continuing Education and Email: ocewd@lcc.hawaii.edu
Workforce Development Website: www.ocewd.org

PARTICIPANT INFORMATION
Participant Name (Last, First, MI): Date of Birth (Month/Day/Year):

Street Address: City: State: Zip:

Phone (Home) Phone (Work) Phone (Cell) Driver’s License No. Driver’s License Issuing State:

Email: Primary Language Spoken at Home: Interpreter


Needed?

I fully understand the OCEWD Non-Credit Registration Policy and all applicable policies of Leeward Community College.

Student Signature: _________________________ Date: _________ Parent Signature______________________ Date: _________


(if student is under 18 years of age)
COURSE REGISTRATION
Course Start Start
No. Course Title Date: Time: Tuition

TOTAL TUITION: $ _______


PAYER INFORMATION (If different from the participant)
Contact Person (Last, First, MI): Company / Agency:

Phone (Work) Phone (Fax) Email

Street Address: City: State: Zip:

PAYMENT INFORMATION
❒ Purchase Order No. _________________
please fax P.O. to 808-453-6730 ❒ Company / Agency: _____________________________________________
I hereby authorize the Office of Continuing Education & Workforce Development of LCC to
invoice for the cost of such course(s) for the above participant. Purchase order acceptance is Signature: ______________________
subject to the approval of the Director of OCEWD.

❒ Check or Money Order No.:__________________ ❒ Cash Amount: $_________


❒ Credit /Debit Card (Visa or Master Card Only) – Note: You may call the office to forward your number
Card number: ______________________ CCV#: _____ Name as printed on card: _______________________ Expir. Date:
_______

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