EASTFall2011 - Northeast Wisconsin Technical College

NwTC REGISTRATION FORM
Print all information using black ink only (Make checks payable to NWTC)
Register online, visit our website at
www.nwtc.edu
Student Number National ID (SS#) Last Name
First Name Middle Initial Previous Last Name
Street Address City
State Zip Code
q Male
q Female
Check one:
q U.S. Citizen
q Immigrant
q Nonimmigrant
Area Code
Area Code
Home Telephone
Legal
Resident
of:
County q Village q City q Town
Work Telephone Area Code Cell Phone Number Date of Birth
Required Government Statistical Information
q 1. American Indian/
q 4. Hispanic/Latino
Alaskan Native
q 5. White
q 2. Asian
q 6. Native Hawaiian or
q 3. Black or African American other Pacific Islander
Education: Name of High School
q High School
q HSED
q GED
City State
®
H.S. Year Graduated
Highest Grade Completed
Disability: q Yes q No | Check ‘Yes’ if you are self identifying a disability.
Class Number Class Title Catalog Number Start Date
Class Fee
For registration information,
call (920) 498-5444 or
toll-free (888) 385-NWTC.
Out-of-state residents may be responsible
for additional fees.
GED ® and the GED Testing Service ® are registered trademarks of the American
Council on Education ® and may not be used or reproduced without the express
written permission of the American Council on Education.
SOURCE CODE: ACE
I certify that the information on this form is true to the best of my knowledge.
Signature (required) ___________________________________________________________ Date __________________
Mail-In Registration
Registrations are processed by postmark dates. Checks
should be made payable to Northeast Wisconsin Technical
College and mailed WITH REGISTRATION FORM to:
Northeast Wisconsin Technical College –
East Regional Learning Center
133 Commerce Drive/Hwy 54, Luxemburg, WI 54217
Payment for all non-credit
classes is required at the
time of registration.
NWTC accepts
Fall 2011 • NWTC East Region • Page 33