PCATT Registration Request Form

Instructions
  • Use this participant Registration Request form to select your preferred course(s)
  • Please use one Registration Form per campus
  • Fill in the blanks. Required information is indicated with an *
  • Print, then Fax or mail it to the appropriate location
Registration requests are processed in the order that they are received. You will receive via email the status of your selections, usually within one working day.
Participant Information
Social Security Number:

Mr.*
 Ms.*
 First Name: *
 Last Name: *
 M.I.
 Title:
HOME ADDRESS
Street Address:


City:
 State:
 ZIP:
BUSINESS ADDRESS
Business Name:

Street Address:


City:
 State:
 ZIP:
CONTACT INFORMATION
Day Phone:*
 Evening Phone:
 Business Phone:
 Cell/Pager:
Email:* FAX:
Course Information
Course Code Start Date Title Fee
    Total
Method of Payment
  • Choose one of the methods below; 1) Check, or 2) Credit Card, or 3) Purchase Order.
  • Please enter all information for whichever method you choose.

1) CHECK

2) CREDIT CARD
Visa
 MasterCard
 Card Number:
 Exp. Date:
 Name On Card:
3) PURCHASE ORDER (Include Purchase Order)
Purchase Order Number:
Compay Name:

Street Address:


City:
 State:
 ZIP:
Parking Permit
  • A parking permit is required for parking in Honolulu Community College campus. Please complete this section if your course seclection is offered at Honolulu Community College.
Driver's Licence # State Issued Make of Car
Body Style Color Car Licence Plate # State
Registered Owner
Address of Registered Owner
Liability Insurance Co.