Please use BLOCK LETTERS

________________________________________________      _____-_____-_____
Last Name                                           Social Security Number

________________________________  ______      ___ ___ Residency Code
First Name                        MI

_________________________________________________  _______________________
Address                                            E-mail Address

____________________________________   _______  __________
City                                   State      ZIP

____-_____-______________       ____-_____-______________
(Area Code) Home Phone           (Area Code) Business Phone

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Birthdate:  _____/______/19____   Sex: (M or F) _____

Race (select one): 
White(W) ____  Black or African American(B) ____ 
Asian(A) ____  American Indian or Alaskan Native(I) ____
Hawaiian or Pacific Islander(P) ____
Other -- please specify __________________________________

Ethnicity (select one):
Hispanic(H) ____  Non-Hispanic(N) ____
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Please check one:

____ I am a continuing MCCC student

____ I am a new MCCC student

____ I am still in high school

____ I attend ____________________________________ college/university
     and am only taking summer courses.   [Please mail/fax or deliver
     your home school transcripts (unofficial), test scores, or grade
     reports to Registration to satisfy any prerequisite requirements.]


_________ Program Code
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Are you a U.S. Citizen (Y or N)? ____ If N (not), please attach
a photocopy of your I-94 Arrival/Departure Card. Also, are you
a permanent resident (Y or N)? ____ If Y (so), please attach a 
photocopy of your Alien Registration Card.

If N (no) to both, what status do you hold (F-1, B1/2, etc)?_______

If you would like to disclose a disability that may require special 
accommodation, please contact the Counseling Office at (609)570-3517.

Course  Ref.    Course Title            Credit/         Course
Number  Number                          Charge Hours    Fee

______  ______  ______________________  _____           _______

______  ______  ______________________  _____           _______

______  ______  ______________________  _____           _______

______  ______  ______________________  _____           _______

                Total credit/hours      _____

                Total course fees                       _______

                Tuition and fees                        _______

                Registration fee                        $ 25.00

                TOTAL DUE                               _______


PAYMENT: Full payment of tuition and fees must accompany
this registration form.

Check or money order for $________ enclosed.

Credit card customers (select one):

VISA number             __________________________________

MASTERCARD number       __________________________________

CVV2 number       ____________ (3 digit number on back of credit card)

Cardholder name ______________________________ Card Expires on _________

Cardholder address _________________________________________

           City _______________________________ State ___ ZIP ______

Amount charged $ _______________


                Cardholder signature _____________________________


RESIDENCY: Have you or your parent(s) or guardian(s) been 
a New Jersey resident for at least 12 months (YES or NO)? ______


I accept responsibility for my course selection and other information
provided on this form. I understand that academic counseling is available
to help with course selection. I certify that I have met the prerequisites
for the courses for which I am registering. Further, I understand that it is
my responsibility to know the starting date of my classes and refund periods.


Date __/___/20__  Signature ________________________________________