Please use BLOCK LETTERS

Mail to:    Mercer County Community College
                PO Box B
                Trenton, NJ 08690
                Attn: Continuing Studies

__________________________            __________-_______-_________
Student ID (If Known)               Social Security Number (optional)

Birthdate ___/___/___    Sex: M___ F___    New Address? _____(y/n)

___________________________  ______________________  _______  _____________________
Last Name                    First                   MI       Maiden Name

_________________________________________________   ________________________________
Address                                             Email Address

____________________________________   _______  __________
City                                   State      ZIP

_____-______-__________       _____-______-__________       _____-______-_________
(Area code) Day Phone        (Area Code) Evening Phone     (Area Code) Cell Phone

Are you a Senior Citizen (Y or N)? _____

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Although Government agencies require this information from the college, 
your completion of the following items is voluntary.

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) ____
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Are you a US 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)?_______

Couse    Reference   Title                    Dates      Day of     Time        Cost
Number    Number                            Start-End     Week         

______   ______    _______________________   __________   _____   _______    _________

______   ______    _______________________   __________   _____   _______    _________

______   ______    _______________________   __________   _____   _______    _________

Course Number: (e.g. XFW347-081356)
                                                          Registration Fee     $10.00
                                                                (required) 

                                                     Late Registration Fee     $10.00
                                      (required if registering closer than 
                                        2 weeks before course start date.) 

                                                                TOTAL COST   __________


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

Check or money order for $________ enclosed (payable to "MCCC").

Check number ___________

NOTE: Please write the Student Number of each person you are
registering on the check.


Credit card customers (select one): (Visa, Mastercard, American Express)

VISA number                   __________________________________

MASTERCARD number             __________________________________

American Express number       __________________________________

Expiration Date:  ________________

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

Cardholder Name ______________________________ Card Expires on _________

Cardholder Address _________________________________________

           City _______________________________ State ___ ZIP ______

Amount charged $ _______________


                Cardholder signature _____________________________




Date __/___/20__  Signature ________________________________________