Welcome to the spring 2013 semester of Queensborough

QCC Continuing Education Registration Form
LAST NAME FIRST NAME o MALE
o FEMALE
ADDRESS
CITY, STATE, ZIP
E-MAIL ADDRESS
EVENING PHONE DAYTIME PHONE BIRTH DATE
COURSE CODE
SECTION
cccc–ccc–cccc
Title
TUITION
............................................................................................................ $...........................
COURSE CODE
SECTION
cccc–ccc–cccc
Title
TUITION
............................................................................................................ $...........................
COURSE CODE
SECTION
cccc–ccc–cccc
Title
TUITION
............................................................................................................ $...........................
Please make checks payable to:
Queensborough Community College
and mail to:
Office of Continuing Education, Room L-118P
Queensborough Community College, Bayside, NY
11364-1497
Registration Fee $..........15.00*.........
Each add’l child $..........10.00*.......
TOTAL $...............................
* Payable one time per semester.
Special Discounts available
- see page 43
FORM OF PAYMENT
o Check o Bank Check or Money Order (Check #_________)
o Credit Card (indicate below)
Card No.___________________________________________________
Please include extra numbers found on back of card.
Signature_________________________________ Exp. Date_________
One form per student. Incomplete information will delay registration.
This form may be duplicated.
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