____________
_______
STUDENT STATUS
(Select one)
NEW
CURRENTLY ENROLLED
FORMER
(When? ________ )
LEGAL LAST NAME
SOCIAL SECURITY NUMBER (SSN)
CLASS REGISTRATION FORM (Complete all boxes)
QUARTER:
SUM FALL WIN SPR YEAR
To comply with federal laws, we are required to ask for your Social Security Number (SSN) or Individual
Taxpayer Identification Number (ITIN). We will use your SSN/ITIN to report payments made by you
that may qualify for a tax credit or a tax deduction on your income tax return. We may also use this
information to administer state/federal financial aid, to verify enrollment, degree and academic
transcript records, and to conduct institutional research. If you do not submit your SSN/ITIN, you will
not be denied access to the college; however, you may be subject to an IRS penalty of $50. Pursuant to
state and federal law, the college will protect your SSN from unauthorized use and/or disclosure.
STUDENT IDENTIFICATION NUMBER (SID)
–
–
Your SID is assigned to you.
You must use your SID to register for classes, get grades,
pay tuition, and other services.
LEGAL FIRST MIDDLE INITIAL PREVIOUS LAST NAME (if applicable)
ADDRESS - NUMBER & STREET & APT. #, ROUTE & BOX OR P.O.
CITY STATE ZIP
DAY PHONE
–
–
–
–
EVENING PHONE
BIRTHDATE
––
MO DAY YR
QUARTER CODE: ________
DO NOT WRITE IN SHADED AREA
INTENT PROGRAM PURP ADVISOR CODE
Have you been a legal resident* of WA and lived continuously
in WA for the past 12 months?
YES NO
*A student cannot qualify as a legal resident of Washington for tuition calculation
purposes if s/he possesses a valid out of state driver’s license, vehicle registration, or
other documents that give evidence of being a legal resident in another state.
If NO, how long have you lived continuously in the state of WA?
Were you claimed for federal income tax purposes by parent
or legal guardian in the current or past calendar year?
If YES, has parent or legal guardian lived continuously
in WA for the past 12 months?
Are you active duty military stationed in WA or
spouse/dependent of the same?
Are you WA National Guard or spouse/dependent of
the same living in WA?
EDUCATIONAL BACKGROUND
YES NO
YES NO
YES NO
YES NO
Last High School Attended City State Year Graduated
YES NO
Last College Attended City State Year Graduated
YES NO
STUDENT’S PURPOSE:
What is your main long term goal for attending Pierce College?
Circle the number that BEST applies to your reason for enrolling:
11 Take courses related to current or future work
12 Transfer to a four-year college
13 High school diploma or GED
14 Explore career direction
15 Personal enrichment
90 Other
BE SURE TO COMPLETE IMPORTANT
INFORMATION ON REVERSE SIDE OF THIS PAGE.
I understand that I am fully responsible for paying my tuition and other
debts owed to Pierce College by the tuition due date. Failure to make
payments to Pierce College by the due date may result in my account being
referred to an outside collection agency. I am responsible for all costs
including collection cost of 24% to 35%, 12% interest and reasonable legal
fees as per Washington State Law.
U.S. CITIZEN? YES NO If No, what is your status?
RESIDENT ALIEN/IMMIGRANT REFUGEE
STUDENT VISA VISITOR OTHER _______________
DISABILITY STATUS
Optional (Confidential information used for statistical reporting only)
Do you have a physical or mental impairment which substantially limits one or more major life
activities, such as: seeing, hearing, speaking, walking, learning or working? YES NO
Persons with disability may be eligible for support services and should contact Access and
Disability Services.
A
if
Audit
ITEM NO. COURSE DEPT. & NUMBER CRE DAYS TIME OFFICE USE
9999 Circle Item # if you want to donate $1 to Pierce College Foundation to provide student scholarships.
TOTAL
*
If you do NOT wish to receive credit, put an “A” in the audit column.
TOTAL
CREDITS
STUDENT
/ /
SIGNATURE X
I accept full financial responsibility as a result of my registration.
DATE
ADVISOR’S
/ /
SIGNATURE X
REFUND POLICY
PLEASE SEE THE ONLINE QUARTERLY
CLASS SCHEDULE FOR COMPLETE
REFUND INFORMATION.
DATE
1507 AF
