CORPORATE EDUCATION
REGISTRATION FORM
Brockton Campus
One Massasoit Boulevard
Brockton, MA 02302
Canton Campus
900 Randolph Street
Canton, MA 02021
Middleborough Center
49 Union Street
Middleborough, MA 02346
massasoit.edu
508-588-9100
CRN COURSE/SECTION COURSE TITLE DATE, TIME & LOCATION COST
Completed forms may be submitted by mail,
in-person, or by fax or email.
Mail to: One Massasoit Boulevard
Attn: Steven Litco, Corporate Education
Brockton, MA 02302
Fax: 508-427-1250
Email: slitco@massasoit.mass.edu
4. PAYMENT INFORMATION
Check Included
Company will pay for training via invoice. Copy of W9 required.
Employer Authorization:
Name
Title
Signature
2. COURSE INFORMATION
Last Name First Name Middle Name
Home Address City State Zip
Cell Phone Date of Birth - REQUIRED - (MM/DD/YYYY)
Work Email Address
Have you taken a course or training at Massasoit Community College before? Yes No If yes, when?
Gender Male Female
Veteran Dependent of Veteran Member of Armed Forces
Do you consider yourself to be Hispanic/Latino? Yes No
Please select one or more of the following that best describes you:
American Indian/Alaska Native Asian
Black/African American Cape Verdean
Haitian Native Hawaiian/Pacific Islander
White/Caucasian
Please be advised that ceasing to attend a class DOES NOT constitute a withdrawal.
Withdrawals from a course must be received in writing at least 24 hours prior to the
start of the course for a 100% refund. No refunds after the 1st class meeting.
Student Signature Date
Please note that Massasoit is required by federal guidelines to report a student’s legal gender.
1. STUDENT INFORMATION
Company Name
Company Address City State Zip
Company Phone Number
3. EMPLOYER INFORMATION
Electrician D - NFPA Part 3
10/24/2019 - 12/12/2019, 6:00 PM -
10:00 PM, Canton
click to sign
signature
click to edit
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click to sign
signature
click to edit
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