Continuing Education
2020 Motorcycle Rider Program Registration
APPLICANT INFORMATION
Please enter your name as it appears on your driver’s license.
First Name MI Last Name Banner ID (if known)
Email* Date of Birth
Today’s Date
Street Address
Apt. #
City State Zip
Home Phone Work Phone Cell Phone
Gender
n
Male
n
Female
Do you plan to use your own scooter (250 cc or smaller) for the class?
n
Yes
n
No
If yes, you must fill out the appropriate box on the State of CT Registration form enclosed.
How did you find out about the motorcycle program at MCC?
METHOD OF PAYMENT
Basic Rider Course Fee: $220 (BRC). Returning Rider Course Fee: $130 (RRBRC). Select method of payment type below. Make checks payable to MCC.
Indicate Method of Payment Type (check only one):
n
American Express
n
Discover
n
Master Card
n
Visa
n
Money Order
n
Check #
_____________________
Credit Card Number
CVC Code
Expiration Date
Cardholder Name (print)
Relationship to Student
Cardholder Address
Cardholder Signature Total Payment
LIST COURSES:
Note: Classes are on a first-come, first-served basis. Please select two or three preferred course sections to help ensure entry into a class. You will be enrolled in your
second or third choice if your higher choices are full. Make sure all dates fit your schedule. *Confirmation of the section that you are enrolled in will be sent from
ceinfo@manchestercc.edu to the email you provided above. Please be sure that it is a valid email address that you regularly check and allow filters to receive the
MCC email. There will be no confirmations sent via U.S. mail. If enrolling with a friend, all registrations must be received together.
Please note the Refund/Rescheduling policy listed in the enclosed packet of program information before registering.
CHOICE
CRN #
1
2
3
START AND END DATES BRC # NUMBER OF SESSIONS
Student Signature Date
January 2020/PR
