Registration Form for Non-Credit Courses

INSTRUCTIONS: Complete this Form, Print it, and Mail to the Address Below or use our new Secure On-Line Registration Form.

Name SS#
Home
Address
Birth Date
City State   Zip
Phone (Home) (Work)
Business
Name
Business
Address

Check if New Address       e-mail address

How did you hear about the course(s)? BCCC brochure BCCC Web site
Newspaper Friend/Relative
TV Radio

Postcard
Other _______________________


Are you taking this course at the request of your employer?    Yes No
Do you anticipate being reimbursed by your employer?    Yes No

Registrant Signature X______________________________________    Sen. Cit. 65+

 

Course No.Course TitleSectionStart DateFee
Do not include materials fees with payment! TOTAL

 

Student ID #
Check No. Check issued by
Credit Card # Exp. Date

For courses which are $10 or more, there is a $25 non-refundable fee for any cancellation.

Payment

Make checks payable to: Bucks County Community College and Return to:

Continuing Education, Bucks County Community College
275 Swamp Rd., Newtown, PA 18940
(Fax) 215-968-8320