Fillable Form 1606: Non-Credit DD214 DO NOT WRITE IN

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Form 1606: Non-Credit DD214 DO NOT WRITE IN

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Country of origin: US
File type: PDF

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CREDIT CARD#
CRN# DEPT & COURSE # COURSE TITLE
# OF
CREDITS
TIME
FROM – TO
DAYS
ROOM
M T W R F S
M T W R F S
M T W R F S
M T W R F S
M T W R F S
M T W R F S
M T W R F S
M T W R F S
The student meets the prerequisites required for the above course(s) by presenting
ACT/
AP/SAT Scores,
Placement Scores, or
Unofficial Transcript.
Please list CRNs: ____________________________________________________________________ Advisor Initials: _______________
Once this registration is processed, you are responsible for the charges associated with registration. Detailed information about this
and other College Policies can be found in the MxCC College Catalog on our website. It is the responsibility of each student to read the
policies of Middlesex Community College. The student’s signature on this form is acknowledgement of receipt of this statement and
acceptance of the terms and conditions of all policies.
TODAY'S DATE
ADVISOR'S SIGNATURE
TOTAL CREDITS
STUDENT'S SIGNATURE
REGISTRATION FORM
MxCC REV
03/20
MIDDLESEX COMMUNITY COLLEGE
OFFICE USE ONLY
DO NOT WRITE IN THIS SPACE
CPE
Employee Waiver
High School Partnership
Non-Credit
Platt High School Seat
Senior Citizen
Veteran:
31
33
1606
DD214
EXPIRATION DATE &
CVV
#
SIGNATURE
DISTRIBUTION:
White – Enrollment Services Office Pink - Business Office
STUDENT ID:
@
THIS REGISTRATION IS FOR:
□
FALL
□
SPRING
□
SUMMER
□
INTERSESSION
YEAR ___________
SOCIAL SECURITY #
NAME: LAST FIRST MAIDEN NAME OR MIDDLE INITIAL
ADDRESS (NO. AND STREET)
□
PLEASE CHECK HERE IF CHANGE OF ADDRESS
CITY/TOWN
STATE
ZIP CODE
PHONE: HOME
PHONE: CELL
EMAIL ADDRESS
□
PLEASE CHECK HERE IF CHANGE OF EMAIL ADDRESS
DATE OF BIRTH
/ /
GENDER
□
MALE
□ FEMALE
US VETERAN
□
YES
□ NO
STUDENT STATUS:
□ NEW
□ CONTINUING
□ READMIT
SEMESTER LAST ATTENDED: □
FALL
□
SPRING
□
SUMMER
□
INTERSESSION
Y
EAR ____________
N/C 3rd Party Funding Source: ________________
If you're emailing this form, do not include
SSN. If it’s required, you'll be contacted.
If you're emailing this form, do not include credit card number.
If it’s required, you'll be contacted.
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Form 1606: Non-Credit DD214 DO NOT WRITE IN

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Completed 25 July 2020

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