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:

I have read and agree to the Privacy Policy *

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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.