NAME – PLEASE PRINT
LAST FIRST M.I.
MAIDEN OR PREVIOUS LAST NAME
PERMANENT HOME ADDRESS – PLEASE PRINT
STREET CITY STATE ZIP COUNTY
PHONE NUMBERS – PLEASE PRINT
PAYMENT DETAILS – PLEASE PRINT
GENERAL – PLEASE PRINT
EMAIL ADDRESS DATE OF BIRTH
Gender T M
T F
TODAY’S DATE
TO REGISTER, LIST COURSES BELOW. SEE CATALOG OR VISIT WWW.SUNYULSTER.EDU FOR COURSE CODES, START DATES AND COURSE FEES.
HOME PHONE CELL PHONE
BUSINESS PHONE
OFFICE USE COURSE CODE COURSE TITLE COURSE START DATE COURSE FEE
TOTAL $
A UNIT OF THE STATE UNIVERSITY OF NEW YORK
AN AFFIRMATIVE ACTION / EQUAL OPPORTUNITY COLLEGE
NONCREDIT REGISTRATION
Kingston Center of SUNY Ulster
94 Mary’s Avenue, Kingston, NY 12401
845-339-2025 • Fax 845-331-2331
www.sunyulster.edu
CREDIT CARD NUMBER
EXPIRATION DATE CVC CODE
CARDHOLDER NAME (AS IT APPEARS ON CARD)
BILLING STREET ADDRESS BILLING ZIP CODE
This information is voluntary
Are you Hispanic / Latino?
T Yes T No
If Hispanic, your background
(select one)
T Central American
T Mexican
T South American
T Dominican
T Puerto Rican
T Other Hispanic / Latino
Are you? (select all that apply)
T White
T Black / African American
T Asian
T American Indian / Alaska Native
T Native Hawaiian /
Other Pacific Islander
T Non-Resident Alien
Are you a Veteran?
T Yes T No
Do you have a disabling condition?
T Yes T No
LOCATION CODES
KSU
Kingston Center
of SUNY Ulster
94 Mary’s Avenue
Kingston, NY 12401
SRC
Stone Ridge Campus
491 Cottekill Road
Stone Ridge, NY
12484
CHECK / MONEY ORDERS
PAYABLE TO UCCC.
LIKE US!
SUNY Ulster Continuing &
Professional Education
A STATE UNIVERSITY OF NEW YORK COMMUNITY COLLEGE
Start Here. Go Far.
STUDENT U#
