COURSE PRE-REGISTRATION FORM

To enroll in face to face or online courses, please complete the following online, registration form below. Be sure to use your complete name (Last, First, and Middle Initial). To secure or finalize class seating and enrollment, visit the online "Tuition Payment Center" on this website. Thank you!

* Required fields
Name *
E-mail Address *
Mailing Address
City/Town
State
Zip Code
Home Telephone Number
Daytime/Work Telephone Number
Identification No. (Last 4 digits of Social Security No.)
School/Organization/Institution/Company You are Affiliated With Along with Contact Supervisor's Name, School/School District Address & Funding Code
Education Service Requested *	Grades 3-12 Tutoring/Supplemental Ed. HomeSchoolEducation Test Preparation(SAT, PRAXIS, GRE, MAT) Seminar(C.E.U.credit)Online/Face 2 Face Mini-Online Six Wks.Course(C.E.U.'s) Independent Study (Six-weeks C.E.U.s) Independent Study (Semster Course) Music Education-Instrumental Classes College Success Program ED2GO Online Course(s) Financial Aid Assistance Thesis/Dissertation Assistance General Consultations Diagnostic/Achievement Testing Other:_________________________
Course(s) / Seminar(s)You Are Registering For (Including Course No., Title, and Cost)
Enrollment Program Type:
Class Session/Semester You Are Registering For: *
Preferred Day and Time for Class (Please indicate two optional time slots)
REGISTERING FOR ED2GO ONLINE COURSE(S)	YES NO
Total Tuition Cost for Registered Course(s) and/or Seminar(s):
Form of Payment for Tuition
Name of College(s) or University(ies) Attended:

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For non-electronic tuition payments, please mail your payment to: Student Support Services, DeLorge International University Centre, School of Professional Studies, 126 E. Gordon Street, Suite 201, Kinston, NC 28501. For credit card or debit payments, click and visit our secure online tuition payment center.