ACC is committed to the principle of equal opportunity in education and employment. The college does not discriminate against individuals on the basis of race, color, gender, religion, disability, age, veteran status,
nationality or ethnicity in the administration of its educational policies, admissions policies, employment policies, scholarship and loan programs, and other college administered programs and activities.
Please print (FULL LEGAL NAME): TDL #_____________________________________
Last First MI Former Last Name E-Mail Address
Mailing Address Apt. # City State Zip
Home Phone Work Phone Cell Phone Social Security # / Student ID # (Optional) Birth Date
Emergency Contact Relation Phone
Are you a Veteran? Yes No How did you hear about this class?
I have read and understand the REFUND POLICY & payment requested on this form. I understand my class schedule and that I
may be required to purchase textbooks and/or supplies, and a temporary parking permit for the ACC campus. Parking Permits
are obtained from the Campus Police office.
Initial: __________
Authorized Signature Date
ENROLLED IN:
Course Number Course Name Location Starting Date/Time Tuition Fees
TOTAL
3110 Mustang Rd. Alvin, TX 77511
Phone (281)756-3787
Fax (281)756-3952
A student must submit a written withdrawal request from a CE course up to 5 working days prior to the class start date and receive a refund, less
a $20 cancellation fee per class. NO REFUNDS AFTER THAT DATE. If ACC cancels a course, 100% of your payment is refunded. Credit overlay
courses will be refunded per credit guidelines. Allow 2-3 weeks for refund checks to be mailed.
Please provide the following information if this is your first course through Continuing Education
(voluntary for federal/state reporting):
What is your ethnicity/gender? White, Non-Hispanic Black, Non- Hispanic Hispanic Asian/Pacific Islander American Indian/Alaskan Native
Male Female
Which independent school district do you live in? Alvin ISD Pearland ISD Other:______________________
Do you need reasonable accommodations to attend? Yes No Do you have a high school diploma or GED? Yes No
FINANCIAL AIDE: □ TPEG $___________ □ GRANT $___________ □ SCHOLARSHIP $___________
STUDENT INFO: STUDENT ID # ______________________ CASHIER TRANSFERRED TO: ___________________________
QUARTER(S): ______________________ AMOUNT OWED BY STUDENT: __________________________
□ INFORMED STUDENT TO UPDATE ADDRESS/PHONE NUMBERS/EMAIL/OTHER AT THE ESC
Company/Agency Name Contact Person
Street Address City TX Zip Phone Number
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