EMPLOYER SPONSOR INFORMATION FORM
STUDENT INFORMATION
Student ID# Birth Date
Gender M F Other
Last Name First Name MI
Street Address
City State Zip
Phone Number (Home)
Phone Number (Cell)
Email Address
______I authorize MCCC to release attendance and grade information to the below named employer.
______By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper.
Course/Section Title Dates Day of week Time Cost
Total Cost
Payment: Total Cost is due upon registration. A Refund can be issued ONLY if you withdraw from a course ten or more days before the start of
class. Credit card payments will be refunded to the credit card; cash and check payments will be refunded via a check from MCCC made payable
to the student.
Credit Card Type: Credit Card#
Exp. Date CVV# (3 digit # on back)
Card Holder Name Amount to be Charged
Card Holder Address
City State Zip
PAYMENT INFORMATION
Mail registration form to
The Center for Continuing Studies
1200 Old Trenton Road, West Windsor, NJ 08550 or e-mail to ComEd@mccc.edu. DO NOT SEND CASH.
EMPLOYER INFORMATION
Company Name/Organization _______________________________________ authorizes MCCC to register the student listed for
the continuing studies classes listed below and will take responsibility for payment of all tuition and fees.
*Please reimburse your employees directly for the books purchased from the bookstore.
Managers Name Title
Phone Number Fax Number
Email Address Mailing Address
City State Zip
Billing Department Contact Title
Phone Number Fax Number
COURSE INFORMATION
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