Name:
Have you previously attended Hudson Valley Community College? If yes, please list any other names your academic
record may be listed under.
SS# D.O.B. Sex Code M=Male/F=Female
Address:
City, State, Zip
Email address:
May we contact you via email? r Yes r No
Telephone (Home): (Work): (Cell):
PAYMENT INFORMATION
r
Check
r
Voucher/PO (attached)
r
Tuition Waiver
r
MasterCard
r
VISA
r
Discover
Card #: Exp. Date:
3# security code: Cardholder’s name:
COURSE INFORMATION
CRN # Course Name Fee
CRN # Course Name Fee
CRN # Course Name Fee
CRN # Course Name Fee
TOTAL: $
HOW DID YOU RECEIVE OUR BROCHURE?
r From Community & Professional Education r Mail
r From a friend r The college website
r Community location (store, library, etc.) r Other:
MAIL COMPLETED REGISTRATION AND PAYMENT TO:
Hudson Valley Community Office of Community and Professional Education
80 Vandenburgh Avenue, Troy, New York 12180
Registration Form
Community & Professional Education
First Middle Last
NEED ANOTHER FORM? Visit our Website at www.hvcc.edu/communityed/comedreg.pdf.
PLEASE - ONLY ONE STUDENT PER FORM. Thank You!
Community Education • (518) 629-7339
WEB