Order Form

Items marked with * are required.

Student Information:

First Name:*
Last Name:*
Birthdate:* (Example: 06/15/1978)	/ / (You must be 18)
Sex:*
Race:*
Highest Education Level:*
Employment Status:*
Military Status/Affiliation:*

Billing Address - This address must match the credit card you will be using

Address Line 1:*
Address Line 2:
City:*
State:*
Zip Code:* (Example: 75075)

Shipping Address: Check if the same as billing

Address Line 1:*
Address Line 2:
City:*
State:*
Zip Code:* (Example: 75075)

Phone/Email:

Telephone:* (Example: 909-693-8475)
Fax: (Example: 909-693-3764)
Email Address:*

Payment Information:

Cardholder's Name:*
Credit Card Type:*
Credit Card Number:*
Card Security Code:*	where to look?
Expiration Date:*	/
IMPORTANT: If you are registering and paying for a class online, please note that the FTCC Business Office (BO) will be reviewing your record to ensure there are no unpaid expenses due on your student account. If these are discovered, the registration fee that you pay through the Learn FTCC website will automatically be applied to the unpaid expenses on your student account, and a representative from the FTCC BO will contact you to facilitate your payment of the remaining balance on your student account and payment of the registration fee associated with your desired online course or courses. For additional registration and payment questions, please call (910) 678-8386 (Registration) or (910) 678-9846 (Payments). Thank you for choosing FTCC!

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