- Page 1
- Page 2 - Page 3 - Page 4 - Page 5 - Page 6 - Page 7 - Page 8 - Page 9 - Page 10 - Page 11 - Page 12 - Page 13 - Page 14 - Page 15 - Page 16 - Page 17 - Page 18 - Page 19 - Page 20 - Page 21 - Page 22 - Page 23 - Page 24 - Page 25 - Page 26 - Page 27 - Page 28 - Page 29 - Page 30 - Page 31 - Page 32 - Page 33 - Page 34 - Page 35 - Page 36 - Page 37 - Page 38 - Page 39 - Page 40 - Page 41 - Page 42 - Page 43 - Page 44 - Page 45 - Page 46 - Page 47 - Page 48 - Flash version © UniFlip.com |
Summer 2018 Credit & Noncredit Registration Form
Please print clearly.
Student Information We need this information to contact you in regards to course updates.
Social Security Number: Name:
Last First MI
Citizenship
Birthplace: ________________________________________ Are you a United States Citizen?: q Yes If no, permanent resident?: q Yes
q No
q No
q Female
q Male
Date of Birth:
Month
Day
Year
Country of Citizenship: _____________________________
Current Address:
Ethnic Group
Street Number and Name
Answer both A & B below
a. Ethnicity: Are you Hispanic or Latino origin?: q Yes q No
City State Zip Code
b. Race: Choose one or more from the list below: q African American/Black q White/Caucasian q Asian q No q Native Hawaiian/Pacific Islander q American Indian or Alaskan Native Is English your first language?: q Yes
Phone Number (Home): Phone Number (Work): Phone Number (Cell): E-mail:
Area Code
Phone Number
Extension
Area Code
Phone Number
Extension
Area Code
Phone Number
Extension
If no—Primary Language: _________________________________
High School Information (for credit students only)
Did you earn a High School Diploma?: Name of High School: Date of graduation:
month/year
q Yes
q No
HiSET or GED?: q Yes
q No
month/year
Date of GED or HiSET certificate: ____________________________
If you graduated from high school in 2003 or later, check one:
q I earned my high school diploma and met MCAS requirements q I earned my Massachusetts Certification of Attainment q I earned my high school diploma from a school that did not have MCAS requirements
I certify that all information stated on this application is accurate and complete.
Applicant’s Signature:
CRN# 10074 Course# ART 126 Section# 30 Course Title Painting I - (sample) Credits 3 Day MW Location HH-107
Date:
Lab Fee 0 Course Charge Total
Method of Payment
q Cash
q Check
q Other (If paying by credit card please be sure to fill in information in charge accounts box below)
Charge Accounts
We accept Discover, MasterCard and Visa payment of tuition and fees. Complete all items below if you are charging a course or registering by Fax. Note: Refunds are applied to the card account.
q Discover
q MasterCard
q Visa
Account Number: _______________________
Expiration Date: _______ Amount Charged: ________
month/year
Cardholder’s name (please print): ______________________________
Cardholder’s authorizing signature: _____________________________________
Make full payment by check, money order, or credit card payable to MCC. Minimum Credit Card Charge must be $10. Mail to: MCC Lowell Campus-Enrollment Management Center, 33 Kearney Square, Lowell, MA 01852-1987 Special Registration Lines: 1-800-818-3434 from 8:30am-8:30am Mon-Thurs. and Friday 8:30am-6:30pm Fax to: 978-656-3443 Web: www.middlesex.mass.edu and click on the MiddleNet button.
|