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 |
||
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 Title | Section | Start Date | Fee |
|---|---|---|---|---|
| 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
