non-CREDIT REgIsTRaTIon FoRm
First Name Last Name MI
Mailing Address
City State Zip Code
Email Address
Student Status (circle one)
New (first time at NCCC or any CT Community College)
Returning (Attended NCCC or other CCC. Were you registered under
another name? If so, please print name. ie Maiden name)
Social Security No. Sex (circle) Date of Birth
- - M F / /
Phone (H) Phone (Cell)
( ) ( )
CT Resident (circle) US Citizen (circle)
Yes No Yes No
Ethnicity
q Hispanic or Latino
q Non-Hispanic/Non-Latino
q Choose not to respond (none)
Race
q White(10)
q Black or African American(20)
q Asian(45)
q American Indian or Alaskan Native(50)
q Native Hawaiian or Other Pacific Islander(80)
q Other (90) q Choose not to respond (60)
Center for Workforce Development
Non-Credit Registration Form
Mail to: Northwestern Connecticut Community College
Park Place East / Winsted, CT 06098 / Phone: 860-738-6484 or 860-738-6444 / Fax: 860-738-6453
CRN# Course Title CEU Dates Fee
REFUND POLICY: NCCC reserves the right to change instructors, cancel or
reschedule a program in the event of insufficient enrollment or unforeseen
circumstances. If your course is canceled, you will have the option of
applying your course fee to another class or you will receive a full refund. If
you are unable to attend a course you must withdraw at least FIVE WORKING
DAYS before the first scheduled meeting in order to receive a refund. Some
programs have different payment options and/or limited refund policies.
Contact us for details.
X
q Visa q Mastercard
q Discover Number ___________________________________________________________________________________
Billing address zip code_____________________________________________________________________________________________________
Expiration Date___________________________________________________3 Digit Security Code________________________________________
Name on Card____________________________________________________________________________________________________________
Three ways to register:
FAX: Fax the registration form with your Mastercard/Visa/Discover information to (860) 738-6453
IN PERSON: Bring the registration form and payment to the Center for Workforce Development, 56 Park Place East, Monday-Friday between 9am - 4pm.
MAIL IN: Send this registration form to the above address along with a check or money order payable to NCCC or Mastercard/Visa/Discover information.
Course fees are payable at the time of registration. You are registered for a class unless notified otherwise.
TOTAL
q Cash q Check or Money Order payable to NCCC.
Payment Method :
X
I certify that the information provided above is, to the best of my knowledge,
true and correct, and I consent to the disclosure of this and program
participation information between Northwestern Connecticut Community
College, Connecticut State Colleges and Universities and state and federal
Departments of Labor for the purpose of maintaining accurate student records
and to monitor grant performance.
Student Signature--I have read the disclosure agreement
Student Signature--I have read the refund policy
Date
Date
DISCLOSURE AGREEMENT:
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