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
Website: www.ocewd.org  
Workforce Development

PARTICIPANT INFORMATION
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?

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

Phone (Work) Phone (Fax) Email

Street Address: City: State: Zip:

 
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:      $  _______  

PAYMENT METHOD
❒ 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: _______