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Personal Information

Last Name *
  
First Name *
  
Middle Name
  
Salutation  
  
Name to Appear in Print
  

Email Address*


Contact Information

Address *

Preferred
Type *
Address 1 or Business Name *
Address (line two)  
 
City *
State/Province *
Zip/Postal *
 
Country *
Other State (International Students)  
   

Telephone / Fax*

Please include international dialing information in the area code field if applicable.
Preferred
Type 
Area 
Number
Ext. 

Preferred Contact Method

Which method of communication would you prefer?*      

Your Employment Information





Shared Information

Additional Information

Have you previously enrolled in courses and programs delivered by Extended Academic Programs Continuing Education?
Yes No

  May we contact you about courses that we think may interest you? *
  Yes, by any method

  Yes, but only by the following methods (please check the methods that we may use to contact you)
       Email Mail Phone

  No, please do not contact me

Learning Goals
Interests
Enrollment Timeframe

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Other Learning Goals
Other Timeframe

Email Password

Would you like us to email a user name and password to you so that you do not need to re-enter your contact information when you make another inquiry, or when you register for a course?

Yes No
The Family Educational Rights and Privacy Act (FERPA) is a United States law that protects the privacy of student records. The Office of Continuing Education, The University of North Carolina at Charlotte must have your explicit permission to release your contact information.

For additional information or assistance, please contact the UNC Charlotte Continuing Education Registration Center at 704-687-8900.