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Division Of Continuing Education - Gloucester County College

Division Of Continuing Education - Gloucester County College

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Personal Information<br />

Last name __________________________ First name ______________________<br />

Social Security #______________________ Birth date ______________________<br />

Home address ______________________________________________________<br />

City, State, ZIP ______________________________________________________<br />

Place of employment __________________________________________________<br />

Work address ________________________________________________________<br />

Phone: daytime________________________ evening ______________________<br />

Fax number ________________________________________________________<br />

E-mail address ______________________________________________________<br />

Course Registration<br />

Code Course Title Day (circle) Tuition<br />

Payment<br />

How did you hear about the<br />

program?<br />

1 Course brochure<br />

2 Friend(s)<br />

3 Previous course<br />

4 Work<br />

5 Newspaper<br />

Sex:<br />

1 Male 2 Female<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 Alaska<br />

Native<br />

M T W TH F S<br />

M T W TH F S<br />

M T W TH F S<br />

M T W TH F S<br />

TOTAL COST<br />

Checks: Please make checks payable to <strong>Gloucester</strong> <strong>County</strong> <strong>College</strong><br />

Businesses: Company Purchase Order #_________________________<br />

Credit Cards: All information must be complete and accurate before your registration will be processed<br />

Card # ______________________________________________ Exp. date __________________<br />

Check: M/C VISA DISCOVER American Express<br />

3- or 4-digit Security Code __________________________________________________________<br />

Signature ________________________________________________________________________<br />

Submit this form to:<br />

<strong>Gloucester</strong> <strong>County</strong> <strong>College</strong><br />

<strong>Division</strong> of <strong>Continuing</strong> <strong>Education</strong><br />

1400 Tanyard Road, Sewell, NJ 08080<br />

Fax: 856-468-7023<br />

Federal Reporting<br />

Please note: With the submission of this form,<br />

you are registered. Unless notified to the<br />

contrary, please report to your first scheduled<br />

class. Please feel free to duplicate this form.<br />

The state and federal governments require the <strong>College</strong> to submit information on student characteristics. Your response<br />

to this section is voluntary, but will help GCC implement its affirmative action policy. GCC is an equal opportunity<br />

institution. This information does not affect admission or placement.<br />

<strong>Education</strong>:<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 />

To Register by phone: 856-415-2217<br />

REGISTRATION FORM<br />

41

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