Application for Non-Credit and Continuing Education Classes

Please supply us with the following information as it would appear on legal documents.
Fields starting with * are required.

Note: Gender, Race & Ethnicity items are voluntary and will not be used in a discriminatory manner.


Personal Information

Social Security Number Why is this important?
Enter SSN without dashes or leave SSN blank
Title
* First Name
Middle Name
* Last Name
Suffix
* Date of Birth Calendar Icon  mm/dd/yyyy
Gender
Are you Hispanic/Latino?
Race (optional)



Country of Birth
Country of Citizenship
Employment Status:


Login Information

* Password 8-15 characters
* Verify Password Please remember or record your password.
Passwords are case-sensitive and must adhere to the following rules:
  • The password must be between 8 to 15 characters.
  • The password must be changed every 180 days.
  • The password cannot match the last 24 passwords.
  • The password must contain (3 of 4) of the following:
    1. At least 1 lowercase character.
    2. At least 1 UPPERCASE character.
    3. At least 1 number.
    4. At least 1 special character:
      (!#$%*+,-./:;<=>?@[\]^_`{|}~")

* Password Reset Question
* Password Reset Answer

Contact Information

* Mailing Address
* City
* Zip Code
* State
* Country
* Home Phone (123) 123-1234
Work Phone (123) 123-1234 or (123) 123-1234 ext 1234
Cell Phone (123) 123-1234
E-mail Address Why is this important?
Enter only one e-mail address  


Immigration Information

(To be completed by non US citizens only)
* Immigration Status
Visa Type
Visa Issue Date Calendar Icon  mm/dd/yyyy
Visa Expiration Date Calendar Icon  mm/dd/yyyy



Palm Beach State College
Sign up with Palm Beach State Alerts