Please use BLOCK LETTERS

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

_____-_____-_____       Birthdate ___/___/___ Sex: M___ F___ New Address? _____
Social Security Number

____________________________________________ ____________________________________  ______
Last Name                                    First                                 MI

_________________________________________________ ____________________________
Address                                           Email Address

____________________________________   _______  __________
City                                   State      ZIP

____-_____-______________       ____-_____-______________
(Area code) Day Phone           (Area Code) Evening 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)?_______

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

______  _______________________ __________ _____   _______    _________

______  _______________________ __________ _____   _______    _________

______  _______________________ __________ _____   _______    _________

                                          Registration Fee      $10.00

                                                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 Social Security Number of each person you are
registering on the check.


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 _____________________________




Date __/___/20__  Signature ________________________________________