Course Registration Form
NMCC ID # ________________________ Date of Birth ________________
if none Social Security# ______________________ Sex M F
Last Name__________________________ First___________________________ Middle_____________________
Mailing Address ___________________________________________________________________________________
Street/PO Box Town State Zip
Physical Address ___________________________________________________________________________________
(if different from above) Street Town State Zip
E-Mail Address________________________________________________ Cell Phone __________________________
Home Phone ______________________________ Work Phone______________________________
Maine Resident? Yes No U.S. Citizen? Yes No If No, what country? ____________________
Previous attendance at NMCC? Yes No Maiden/Previous Name while attending ____________________
(if different from above)
DESIRED COURSES Fall Spring Summer 20 ___
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3.
4.
Where are you taking classes this semester? Presque Isle campus Other___________________________
Are you graduating from NMCC at the end of the semester for which you are now registering? Yes No
Major (if applicable)________________________________________________
Are you a senior citizen (65 years of age or older)? Yes No
Is the course you are taking offered through:
Concurrent Enrollment Yes No EMBARK Yes No
High School Aspirations Yes No If yes, MEDMS ID# required (available from guidance): __________________
Is a third party (i.e. employer, EMBARK, high school) responsible for paying for your course? Yes No
If yes, please list (be specific): _______________________________________________________
Military Status: Veteran (utilizing benefits) Active Duty Military Not Applicable
Veteran (not utilizing benefits) Veteran’s Dependent (utilizing benefits)
Ethnicity (Optional): Hispanic/Latino Not Hispanic/Latino
Race (Optional – check all that apply): American Indian or Alaska Native Asian
Black or African American White
Native Hawaiian or Other Pacific Islander
I would like someone to contact me about additional opportunities at NMCC: Yes No
Student Signature _______________________________________________ Date_______________________________
PLEASE NOTE: Individuals with disabilities who require accommodations must contact the Counseling Office at (207) 768-2839 for assistance.
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