Quincy College

Quincy College Registration Form
Quincy College Use:
ID #
___________________________
Date
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For Quincy Campus:
Quincy College
Admissions Office
1250 Hancock Street
Quincy Center, MA 02169
phone: 617-984-1710
800-698-1700
fax: 617-984-1794
www.quincycollege.edu
For Plymouth Campus:
Quincy College
Admissions Office
36 Cordage Park Circle
Suite #228
Plymouth, MA 02360
phone: 508-747-0400
fax: 508-747-8169
www.quincycollege.edu
Matriculating (Degree/Certificate Seeking) Students Only
All returning Quincy College financial aid students must register for classes online at www.quincycollege.edu
Student ______________________________________________________________________________________________________________________________
Information First Name Middle Name
___________________________________________________________________________ XXX-XX- __________________________________________
Last Name
Social Security Number (last 4 digits only)
Permanent ______________________________________________________________________________________________________________________________
Mailing Number Street/PO Box Apartment Number
Address
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Contact
Information
Course
Information
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City State Zip Country
______________________________________________________________________________________________________________________________
E-mail
(_________)____________________________________________________(__________)________________________________________________________________
Home Phone
Cell Phone
(_________)_______________________________________________________________________________________________________________________________
Emergency Contact Phone
Name and Relationship to Student
May we send text messages about Quincy College to your cell phone? r Yes r No
Quincy College requires that all degree seeking students complete pre-requisites for courses.
Course # Course title Day(s) Time Tuition
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Course Pricing (see tuition information) Cost $ ________________________________
Application Fee (first time students only, $30.00)
Registration Fee ($25.00)
Please note there is a $25 drop fee per course.
Student ID (first time students only, $25.00)
$ ________________________________
$ ________________________________
$ ________________________________
Total
$ ________________________________
#
Advisor’s Signature of Approval ___________________________________________________________________________________________________
r Check r Visa r American Express r MasterCard r Discover
Enrollment staff
Payment
cut here
Information
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www.quincycollege.edu • 800-698-1700
Charge Card __________________________________________________________________________________________________________________________________________
Authorization Card Number Expiration Date
______________________________________________________________________________________________________________________________
CVV2 (Card Verification Value 2 — the 3 or 4 digit number on the back of the card)
______________________________________________________________________________________________________________________________
Name on Card
______________________________________________________________________________________________________________________________
Signature
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