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cced spring 2011booklet - Baton Rouge Community College

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FAXWITHCREDIT/DEBITCARDPAYMENTTO:225.216.8446NEWSTUDENTRETURNINGSTUDENTSTUDENTID:_______________________Pleaseprintortype.Useapencilorblackinkpen.PERSONALINFORMATIONPrintName___________________________________LastFirstMIFormerSignature_____________________________________Address_____________________________________________________________________________________CityStateZipParishNote:PhoneNumbersareusedtocontactforclassinformation.HomePhone_________________________CellPhone________________________Email__________________________________GenderMaleFemaleDateofBirth(Required)____________Mo.DayYr.EthnicCodeBlackAmericanIndian/AlaskanWhiteAsian/PacificIslander/IndianSubcontinentHispanicOtherU.S.CitizenYesNoHowdidyouhearaboutus?BUSINESSORWORKINFORMATIONBusinessName_______________________Title_______________________________Address_______________________________________________________________CityStateZipParishPhone_________________________Fax_________________________PAYMENTINFORMATIONTVRadioWEBNewspaperOtherWCCE# CRN# COURSETITLE STARTDATE FEE Note:NoREFUNDafter1 st dayofclass.NOEXCEPTIONS!CashDiscoverCheckMoneyOrderMasterCardVisaP.O.mustaccompanyregistrationAccountNo._________________________________NameonCard_______________________________Signature___________________________________ExpirationDate______________________________ TOTAL $

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