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.