REGISTRATION FORM
Workforce Development & Continuing Education
Please Print Clearly
All information is required. Incomplete forms will be returned to the student unprocessed. For registration assistance call 240-567-5188.
FAX completed registration form with credit card information to 240-567-1877 or 240-567-5615 or 204-567-7937.
Mail completed registration form with payment to WD&CE Registration, 51 Mannakee Street, CC 220, Rockville, MD 20850.
□ □
College ID Number:
M 2
Birthdate
- -
Sex
Female Male
Month
Day
Year
Last Name First Name
Middle Initial
Address
House # and Street Name (Do NOT use P.O. Box or you will be charged Non-Md. resident fee.)
Apt. #
City
State Zip
-
Home
Work
Phone
Phone
Cell
E-Mail
Have you attended MC before?
□Yes □No
How did you hear about us?
□Received brochure in mail □Website □Social media □Advertisement □On campus □Other_______________
If you have ever taken a credit class at MC and the last class (credit or non-credit) you took at MC was more than 4 years ago, you
must also complete and submit a Student Reactivation form found at: http://www.montgomerycollege.edu/studentforms.
Military: If the military is paying for
your course(s), you must submit the
last 4 digits of your SSN.
STUDENTS WITH DISABILITIES
If you need support services due to a disability, call Workforce Development & Continuing Education at 240-567-4118 at
least three weeks before class begins.
ETHNICITY: Choose one. (Disclosure not mandatory by Montgomery College, but is required by the U.S. Department of Education.)
□Not Hispanic or Latino □Hispanic or Latino
RACE: Choose all that apply, you may choose more than one. (Disclosure not mandatory by Montgomery College, but is required by the U.S. Department of Education.)
□American Indian or Alaskan Native □Asian □Black or African American □Native Hawaiian and other Pacic Islander □White
CHECK ALL THAT APPLY:
□I have been a Maryland resident [as dened in the Montgomery College Catalog] for at least three months.
□I am 60 years of age or older. (Applicable to designated tuition waiver courses for Maryland residents only.)
□I am a Maryland National Guard member enlisted for at least a 24 month period and submitting proof of such from the adjutant general’s ofce.
□U.S. Citizen □Permanent Resident (Circle one: Green Card / Working Card) □Other Immigration Status ______________ (Used for tuition-setting purposes only.)
CRN # Course # Course Title Start Date Tuition Course Fee Non-Md. Fee Course Total
Code: GT Refunds will go to the registered student of record. Total Due
$
I certify that the information on this registration is correct and complete. I am aware of and will adhere to College policies as published in the Student Handbook.
I understand that non-attendance and/or failure to le all registration changes in writing with the Admissions and Records Ofce does not relieve me of responsibility for tuition and
fee charges incurred. I agree to abide by the policies and procedures of the College, including without limitation, the Student Code of Conduct and any payment liabilities. I hold the
College harmless for any errors I have made that may affect a request for a subsequent refund or academic appeal.
_________________________________________________________ ____________________________
Student Signature Required Date
Credit Card Information:
Please indicate payment by:
□Check (payable to Montgomery College) Credit card: □MasterCard □VISA □Discover
3 or 4 digit Security code on your card
Expiration date on card
Month / Year
NOTE:
Credit card information will
be detached and disposed
of promptly and properly
after payment is approved.
Credit Card Number
Name on Card
Card holder
signature required _____________________________________________________________ Date___________________
2/21/17
Montgomery College is an Equal Opportunity Afrmative Action Title IX institution.
ACET Applicant Evaluation
