Download - Welcome
Download - Welcome
Download - Welcome
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Personal Information<br />
Last name ______________________________________ First name _________________________________________<br />
Social Security # __________________________________ Birth year _________________________________________<br />
Home address ______________________________________________________________________________________<br />
City, State, ZIP ______________________________________________________________________________________<br />
Place of employment _________________________________________________________________________________<br />
Work address _______________________________________________________________________________________<br />
Phone: daytime _____________________________________ evening ________________________________________<br />
Phone: daytime ________________________________________ cell ________________________________________<br />
Email address ______________________________________________________________________________________<br />
How did you hear about the program?<br />
1. Course guide 3. Previous course 5. Newspaper<br />
2. Friend(s) 4. Work 6. Other_____________<br />
Course Registration<br />
Code Course Title Day(s) Tuition<br />
Payment<br />
Checks: Please make checks payable to Gloucester County College<br />
Businesses: Company Purchase Order #_________________________<br />
Credit Cards: All information must be complete and accurate before your registration will be processed<br />
Federal Reporting<br />
Card # _______________________________________________ Exp. date __________________ 3- or 4-digit Security Code ______________<br />
Check: M/C VISA DISCOVER American Express<br />
Signature _________________________________________________________________________<br />
Submit this form to:<br />
Gloucester County College<br />
Continuing Education Center<br />
1492 Tanyard Road, Sewell, NJ 08080<br />
Fax: 856-415-7974<br />
The state and federal governments require<br />
the College to submit information on student<br />
characteristics. Your response to this section<br />
is voluntary, but will help GCC implement<br />
its affirmative action policy. GCC is an equal<br />
opportunity institution. This information<br />
does not affect admission or placement.<br />
Sex:<br />
1 Male 2 Female<br />
Education:<br />
1 Less than high school<br />
2 High school<br />
3 Some college<br />
4 Associate degree<br />
5 Bachelors degree<br />
6 Masters degree<br />
7 Doctorate<br />
Race:<br />
1 Asian<br />
2 White<br />
3 Black or African American<br />
4 Hispanic or Latino<br />
5 Two or more Races<br />
6 Native Hawaiian or other<br />
Pacific Islander<br />
7 Non-resident alien<br />
8 American Indian or<br />
Alaska Native<br />
TOTAL<br />
Please note: With the submission of this form, you are registered. Unless notified to the contrary,<br />
please report to your first scheduled class. Please feel free to duplicate this form.<br />
To Register by phone: 856-415-2217<br />
registration form 49