CREDIT CARD INFORMATION/AUTHORIZATION
If you wish to charge your deposit or tuition and fees, please complete the following information:
$ Specify type of charge card:
Amount you wish to charge
Card number
Card Holder’s Signature
Expiration Date Cardholder’s Name
1
2
3
REGISTRATION
FORM
WEB REGISTRATION at www.kellogg.edu
IN PERSON Bring this completed form to the Records and Registration oce in Battle Creek or the oce of the Eastern Academic, Fehsenfeld, or Grahl Center, or the
Regional Manufacturing Technology Center. Photo identication is required.
BY MAIL Return the completed registration form to the address above. A copy of photo identication must be submitted with completed registration form.
NOTE: This method of registration will experience a processing delay.
NOTE: Incomplete registration forms, forms received after the class has begun, and forms from students with a hold on their account will not be processed.
KELLOGG
COMMUNITY COLLEGE
450 North Avenue • Battle Creek, MI • 49017-3397
STUDENT ID or SOCIAL SECURITY NUMBER ARE YOU A U.S. CITIZEN? NON-U.S. CITIZENS
NAME Last First MI In which public K-12 district do you live?
ADDRESS Street Number/Name APT. # TOWNSHIP
CITY STATE ZIP COUNTY
MONTH DAY YEAR MARRIED SINGLE MALE FEMALE
Enter your course selections with information found in the Schedule of Courses.
Please print the following information:
Check ( ) the session and enter the year for which you are registering:
Fall 20 Spring 20 Summer 20
YES NO
VISA Type
Alien Registration Card? YES NO
RACE/ETHNICITY WORK PHONE NUMBER
SUBJECT COURSE SECTION CREDIT
AREA NUMBER NUMBER
HOURS/CEU
SUBJECT COURSE SECTION CREDIT
AREA NUMBER NUMBER
CELL PHONE NUMBER DATE OF BIRTH MARITAL STATUS FORMER/MAIDEN NAME(S) GENDER
TOTAL CREDITS
The information on this form has been provided by me and is true and complete to the best of my knowledge. I agree to provide proof of any information if it is requested.
I understand that false or misleading information may lead to loss of course credit, loss of tuition and fees paid, dismissal from KCC, and/or criminal action.
STUDENT’S SIGNATURE DATE
1.
2.
3.
4.
5.
6.
7.
8.
Are you Hispanic or Latino? Yes No
Select one or more as appropriate: American Indian/Alaska Native Asian Black/African American
Native Hawaiian/Pacic Islander White
(check all that apply)
9/18
“I understand and agree that I am responsible for the payment of the tuition and fees related to my registration. If I am unable to attend my classes, I
understand I am responsible for dropping those classes by the drop add period of the course, otherwise I will be responsible for any balance owed back
to the College. If my account remains unpaid and is turned over to a collection agency, I agree to reimburse KCC for any collection agency fees it incurs,
plus costs and expenses of reasonable attorney’s fees KCC may incur in such collection efforts.
By registering for classes, I accept the terms stated above.”
STUDENT’S SIGNATURE DATE
V-Code
(on back of card) Cardholder’s Zip Code
HOURS/CEU
