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 oce in Battle Creek or the oce of the Eastern Academic, Fehsenfeld, or Grahl Center, or the
Regional Manufacturing Technology Center. Photo identication is required.
BY MAIL Return the completed registration form to the address above. A copy of photo identication 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/Pacic 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
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