Summer 2015 Credit & Noncredit Registration Form
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CRN#
Course#
Section#
Course Title
Credits
Day
Location
Lab Fee
Course Charge
Total
Student Information
Social Security Number:
Name:
Female
Male Date of Birth:
Current Address:
Phone Number
(Home)
:
Phone Number
(Work)
:
Phone Number
(Cell)
:
E-mail:
Last First
MI
Month
Day
Year
Area Code
Phone Number
Extension
Area Code
Phone Number
Extension
Street Number and Name
City
State
Zip Code
Citizenship
Birthplace:
Are you a United States Citizen?:
Yes
No
If no, permanent resident?:
Yes
No
Country of Citizenship:
Ethnic Group
Answer both A & B below
a. Ethnicity: Are you Hispanic or Latino origin?:
Yes
No
b. Race: Choose one or more from the list below:
African American/Black
White/Caucasian
Native Hawaiian/Pacific Islander
Asian
American Indian or Alaskan Native
Is English your first language?:
Yes
No
If no--Primary Language: _______________________________________
High School Information
Did you earn a High School Diploma?:
Yes
No
HiSET or GED?:
Yes
No
Name of High School:
Date of GED or HiSET certificate:
Date of graduation:
If you graduated from high school in 2003 or later, check one:
I earned my high school diploma and met MCAS requirements
I earned my Massachusetts Certification of Attainment
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:
Date:
month/year
month/year
10074
ART 126
30
Painting I - (sample)
3
MW
HH-107
0
Method of Payment
Cash
Check
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.
Discover
MasterCard
Visa Account Number:
Expiration Date:
Amount Charged:
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 Communications Department, 33 Kearney Square, Lowell, MA 01852-1987
Special Registration Lines: 1-800-818-3434 from 8:30 a.m. 8:30 p.m. Monday Friday
month/year
Please print clearly.
We need this information to contact you in regards to course updates.
(for credit students only)
Area Code
Phone Number
Extension
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