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 Title SectionStart 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 $5 non-refundable fee for any cancellation.

Make checks payable to: Bucks County Community College
   
Return to: Continuing Education, Bucks County Community College,
275 Swamp Rd., Newtown, PA 18940
Fax: 215-968-8320