REGISTRATION FORM
Office of the Registrar • Greenwoods Hall Room 215
Park Place East, Winsted, CT 06098
Phone (860) 738-6314 • Fax (860) 738-6413
Semester Registering for: Fall 20____ Spring 20____ Summer 20_____
Student ID No. @______________________
(REQUIRED)
Name ___________________________________________________________________________________
Last First Maiden / Middle Name
Is this a new address: Yes □ No □
Mailing Address ______________________________________________Daytime Phone___________________
Number and street
_______________________________________________________________ Date of Birth________________
City, state, zip
CRN
Course # and
Section
Course Title
Credits
Time
From - To
Days
M T W R F S
BLDG
Rm #
1234
ENG* 101
Composition
3
8:30-9:51
M T W R F S
GW-215
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
A
dvisor/Counselor signature_________________________________________________ Date__________________
S
tudent signature___________________________________________________________ Date__________________
PAYMENT BY: Debit/Credit Card Cash Check #_________ Amount $_________________________
Card Number ______________________________________________________________________________________
Expiration Date____________________ Security Code (on back of card)__________ Billing Zip Code______________
Signature__________________________________________________________________________________________
FEES ARE NON-REFUNDABLE
Registrar’s Approval _____________ Date __________ Waivers Applied _______ Total Credits ______
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