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Credit-Free Classes Registration Form
Street Address City or Town State ZIP Code
Social Security Number Last Name First Name MI
Birth Date Area Code Telephone/Evening Area Code Telephone/Day Ext.
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CRN# Course Title Date Location Cost
E-mail_____________________________________________
Signature ___________________________________________ _________________ ______________________________________
(Your registration cannot be accepted without your signature) Date Occupation
Black, non-Hispanic Hispanic
American Indian White, non-Hispanic
Asian or Pacific Islander
U.S. Citizen
Course information should be provided in the appropriate spaces below (see example on line 1):
Example 11/05/52 = Nov. 5, 1952
Signature __________________________________________________________
Mail or Fax to: (see previous page)
Attached is my check: Payable to: MxCTC
Account Number _____________________________ Expiration Date _________
Charge to my: MasterCard Visa
(To ensure proper credit please put Social Security number on Check)
Total Cost
$
Male
Female
Have you ever attended a Community
College in CT for EITHER a credit OR
credit-free course? Yes No
Please check applicable boxes:
Yes
No
Banner I.D. @___________________
Credits
(If applicable)
