Spring @ SMCC - Southern Maine Community College

Continuing StudiesRegistration FormPLEASE PRINT.Fill out this form and fax to 207-741-5631 or mail to SMCC, Business & Community Partnerships, 2Fort Road, South Portland, ME 04106. For more information, call 207-741-5758. Pay by cash, check,money order, VISA, MasterCard, or Discover.Social Security #:Last Name:First:Middle:Mailing Address:City: State: Zip: County:Home Phone: ( ) Work Phone: ( )Email Address:Amount Of Time I Have Lived In Maine: / Current Maine Resident?: Yes No(For Non-Educational Reasons) Years/Months US Citizen?: Yes NoHave You Previously Taken Courses At SMCC? Yes NoDo You Have A High School Diploma Or GED? Yes NoHigh School Graduation Year:Or GED Year:Your Reason For Enrolling:Degree Or CertificateOtherPersonal EnrichmentTransfer To Another CollegeSkills For EmploymentEthnic Group* (Please Check One)Native American Indian Or AlaskanBlack Or African American, Non-HispanicWhite, Non-HispanicAsian Or Pacific IslanderHispanicOtherGender*: Male FemaleDate Of Birth*: / / (MM/DD/YY)*Optional. This Information Will Be Used For Reporting Purposes Only.Is English The Primary Language You Speak At Home? Yes NoCurrent Year: Semester: Fall Spring SummerCourse Code Course Number Course Section Course Title Credits Official UseCredit Card: MC Visa Discover Number: - - -3-Digit Security Code On Back Of Card:Exp.:Signature:Date:Refund Policy For All Non-Credit Courses: To receive a full refund a student must cancel their enrollment3 business days prior to the start date of the class. There is no partial refund. If a class is cancelled bySMCC for any reason, a full refund will be paid to the student.OFFICE USE ONLY:Date registered: By: Receipt #: Mailed Receipt: YES NO