REGISTRATION FORM
Office of the Registrar • (860)738-6314 • Fax (860) 738-6413
Northwestern Connecticut Community College
Park Place East, Winsted, CT 06098
Semester Registering for: Fall 20____ Spring 20____ Summer 20_____
Student ID @_________________________ Soc. Security No. ______-_____-_____ Date of Birth_______________
Name _________________________________________________________________________________________
Last First Maiden / Middle Name
Is this a new address: Yes □ No □
Mailing Address _________________________________________________ Home phone ____________________
Number and street
_______________________________________________________________ Work phone ____________________
City, state, zip
Email Address (Required)__________________________________________ Cell phone ______________________
Ethnicity: ____ Hispanic/Latino Circle One: New Continuing Reentered
____ Non-Hispanic/Latino High School Graduation Year________ or G.E.D. Year _______
____ Choose Not to Respond Name of High School___________________________________
Highest Degree Earned_________________________________
What is your race? Choose one or more: College Attended______________________________________
_____ White (10)
_____ Black or African American (20) Gender: _____ Male _____ Female
_____ Asian (45)
_____ American Indian or Alaska Native (50) Residency: _____ CT Resident _____ Out-of-State
_____ Native Hawaiian or Other Pacific Islander (80)
_____ Other (90) Citizenship: _____ U.S. Citizen _____ Non-U.S. Citizen
_____ Choose Not to Respond (60)
Advisor’s or Counselor’s signature____________________________________________ Date__________________
PAYMENT BY: □ Visa □ MasterCard □ Discover □ Debit Card □ Cash □ Check #_______
Card Number _______________________________________ Expiration Date ___________ Amount $_______________
Cardholder’s Signature _____________________________________________ 3-digit Security Code___ ___ ___
(on back of card)
Student Signature_____________________________________________________ Date_________________
Registrar’s Approval _____________ Date __________ Waivers Applied_______ Total Credits ____
