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 Ofce 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
4/28/16
Montgomery College is an Equal Opportunity Afrmative Action Title IX institution.
CHECK ALL THAT APPLY:
I have been a Maryland resident [as dened 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 ofce.
U.S. Citizen Permanent Resident (Circle one: Green Card / Working Card) Other Immigration Status ______________ (Used for tuition-setting purposes only.)
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 Pacic Islander White
Military: If the military is paying for
your course(s), you must submit the
last 4 digits of your SSN.
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 240-567-7860 or 240-567-1877 or 240-567-7937.
Mail completed registration form with payment to WD&CE Registration, 51 Mannakee Street, CC 220, Rockville, MD 20850.
Have you attended MC before? Yes No
Month
Day
Year
Female Male
M 2
Birthdate
College ID Number: Sex
- -
City
State Zip
-
Address
Apt. #
House # and Street Name (Do NOT use P.O. Box or you will be charged Non-Md. resident fee.)
Last Name First Name
Middle Initial
Home
Phone
Work
Phone
Fax
E-Mail
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.
CRN # Course # Course Title Start Date Tuition Course Fee Non-Md. Fee Course Total
Code: Refunds will go to the registered student of record. Total Due
$
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
Credit Card Number
Name on Card
Card holder
signature required _____________________________________________________________ Date___________________
NOTE:
Credit card information will
be detached and disposed
of promptly and properly
after payment is approved.
REGISTRATION FORM
Workforce Development & Continuing Education
Please Print Clearly
TST001
CLEP test administration
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