Meridian Community College
Continuing Education & Workforce Development Non-Credit Courses
PHONE 601.482.7445 FAX 601.482.5803 EMAIL:
Social Security Number (required) Date of Birth ____/____/______
Name ____________________________________________________________________________________________
Last First Middle Maiden
Home Address
City ST Zip County
Home Phone Cell Phone Work Phone
Email Address
Employment Status: Employed Unemployed Retired
Employment Type: Full Time Part Time Seasonal
Job Title
Place of Employment
Work Address
Gender: Male Female U.S. Citizen: Yes No
Race: Asian Black/African American American Indian/Alaska Native Hispanic White Other
Education Level: Some H.S. G.E.D. H.S. Graduate Some College AS/AA BS/BA Graduate Degree
You can register for more than one class with this application.
Class(es) in which you are enrolling:
Payment Method: cash check #__________ money order credit card Paid by Employer ______________________
Invoice Company - _______________________________________ Free Class
Total Payment: Date:
The Family Education Rights and Privacy Act provides for the publication or disclosure of certain directory information on students. Check box if you do not want your name, photograph or other
directory information included in publications, Internet or media.
Meridian Community College does not discriminate on the basis of race, color, national origin, sex, disability, religion or age in admission or access to, or treatment or employment in its programs and activities. Compliance with Section 504 is
coordinated by Ms. Soraya Welden, Dean of Student Services, 910 Hwy 19 North, Meridian, MS 39307. 601-484-8628, Fax: 601-484-8635, email:
. Compliance with Title IX is coordinated by Mr. Derek Mosley, Social
Science Instructor, Smith Hall, 910 Hwy 19 North, Meridian, MS 39307. 601-553-3453, Fax: 601-484-8635, email: MCC APP revised 9/13/2017
MCC Non-Credit Refund Policy
All withdrawals and requests for refunds must be made at least one week prior to class beginning. Requests for refunds
will NOT be accepted over the phone. Completion of the MCC Refund Request Form is required. NO refunds will be
given once class has started or if you have attended the class. Meridian Community College reserves the right to substitute
instructors, change class schedules and cancel programs due to insufficient enrollment or unforeseen circumstances. If a
class is cancelled by MCC, you will be given a full refund within 30 days after cancellation.
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