Continuing Education - Capital Community College - Connecticut ...

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Customer Service: (860) 906-5130 Staff Directory Dean, Continuing Education Linda Guzzo (860) 906-5131 lguzzo@capitalcc.edu Health Information Technology Kate Rickard (860) 906-5141 krickard@capitalcc.edu Nurse Aide & Allied Health Ruth Krems (860) 906-5142 rkrems@capitalcc.edu Capital Crossroads to Careers Mary Nerbonne (860) 906-5036 mnerbonne@capitalcc.edu Contact Us Continuing Education/SNAP Ryan Pierson (860) 906-5019 rpierson@capitalcc.edu Continuing Education Nurith Vidal (860) 906-5029 nvidal@capitalcc.edu Capital Crossroads to Careers Cathy Zizka (860) 906-5143 czizka@capitalcc.edu Summer Session Course Schedule Available March 2013 Spring 2013 | 860-906-5130 | www.capitalcc.edu 95
Four Ways to Register BY FAX: (860) 906-5110, ATTN: Olivia BY PHONE: (860) 906-5130, Monday-Friday, 9-4, Mastercard, Visa or Company PO BY MAIL or IN PERSON: Division of Continuing Education, Capital Community College, 950 Main St., Room 316, Hartford, CT 06103 Capital Community College 96 Spring 2013 | 860-906-5130 | www.capitalcc.edu REGISTRATION Division of Continuing Education, Economic & Community Development CREDIT-FREE REGISTRATION Today’s Date: ____/____/____ Social Security Number:_______________ Date of Birth (required): ____/____/____ Last Name:________________________________ First Name:________________________ Middle Initial: ______ Home Address: ________________________________________ E-Mail Address: __________________________ City: _____________________________ State: _________ Zip: _________ Country of Origin: _________________ Home Phone: ( ) _____________ Business Phone: ( ) _____________ Mobile Phone: ( ) ________________ Male Female Yes, I certify that I am a legal resident of CT and have met the 12-month residency requirement. No, I am not a legal resident of CT State of legal residence: ______________________ Are you a U. S. citizen? Yes No If no, are you a permanent resident or green card holder? PAYMENT Yes No Please provide the folloing race and ethnic data. This information is requested on a VOLUNTARY basis by the U. S. Department of Education, Center for Educational Statistics. Your answer will not affect enrollment to, or registration in, the college. ETHNICITY: Hispanic/Latino Non-Hispanic/Non-Latino Choose not to respond RACE: White Black/African American American Indian/ Native Hawaiian/Other Pacific Alaskan Native Islander Other Choose not to respond Dept. No. & Sec. Course Title CEUs Date Time Cost NOTE: Students applying for a SNAP scholarship should indicate their top 3 class choices on this form. How Did You Hear About Us?: _____________________ SIGNATURE: (required) ____________________________________________________ VISA M/C Check (Make payable to Capital Community College, or CCC. NO CASH BY MAIL) Credit Card Number:_________________________________________CVC/Security Code #__________________ Credit Card Holder’s Name: _______________________________Expiration Date: __________________________ Credit Card Holder’s Address (required)______________________________________________________________ Credit Card Holder’s Signature __________________________________________ (Last 3 digits AFTER the credit card number in the signature area of the card.)
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