The Square, Mohawk College | 135 Fenne
l Avenue West, Hamilton, ON L9C 0E5 | Fax: 905-575-2348
If you know your Mohawk College ID, enter it here: Previous student at Mohawk: Yes No
Did you have a previous last name? If so, include it here so we can match your student record.
_____________________________
**Date of Birth: / / **Ontario Education Number (OEN):
(Eg.01/Jan/1968)
Day Month Year
**Gender:
Male
Female
Are you a Canadian Citizen, Indigenous or landed Immigrant?
Yes No
Do you possess a high school Diploma? Yes No
Last Name First Name Middle Name (full not initial)
Unit/Apt Street Address
City Province Postal Code
Home Phone Business Phone Ext Personal E-mail Address
Payment Inform
ation -
Course fees must be paid in full at the time of registration
Cash Debit Certified Cheque* Money Order* Bank Draft* Sponsored Visa Master Card (*Payable to Mohawk College)
Complete b
elow if paying by Visa or Mastercard:
________________
______________________________________________________________________________________________________________________
Cardholder Name as appears on card
________________
______________________________________________________________________________________________________________________
Cardholder Signature Date
Card Number: CVA Number:
Expiry Date: _____ / _____
**NOTE: Date of Birth and Gender are required on the Mohawk College Student Record System to assist in the retrieval of your academic grades, and to issue income tax
receipts | PRIVACY AND CONFIDENTIALITY: Mohawk College collects and retains personal information in compliance with the Freedom of Information and Protection of
Privacy Act (RSO 1990). See the Privacy Statement at mohawkcollege.ca/legal.
Program Name:
Continuing
Education
Full-time
Course Information
Office Use Only
Subject / Course Code
Course Name
CRN
Section
Office Use Only
Department Approval: (Please Print)
(NOTE: Approval may also be given via e-mail to plar@mohawkcollege.ca)
Assessor: Ext: Email:
Emailed Assessor: Emailed Student: PLAR Authorization:
Previous Last Name
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