Kingsborough Community College - Mail / Fax Registration Form

CONTINUING EDUCATION
MAIL /FAX REGISTRATION FORM (Print and mail, or FAX to (718) 368-5200)
Please fill in the semester that you are registering for: (ie. Fall 2010)______________________.

MAIL REGISTRATION FORM FOR ALL CLASSES
CONTINUING EDUCATION- Kingsborough Community College
Last Name______________________________	First Name_______________________
Address:___________________________________	Male________Female_____________
Apt#______________________________________	Birthdate:_________________
City:______________________________________	CK Grade_______
State:_____________________________________	Home Phone:( )___________________
Zip:_______________________________________	Business Phone:( )_________________
E-mail Address:_____________________
Emergency Cell #_____________________________	Emergency Contact:______________________
Course Day Time	Title Tuition




Office of Continuing Education, Room M233 Kingsborough Community College 2001 Oriental Boulevard Brooklyn, NY 11235 Telephone 718-368-5050 Fax # 718-368-5200 Please make checks payable to : Kingsborough Community College Continuing Ed.	Material Fee:$_________ Registration Fee: $25.00 Parking Permit : $22.00 License Plate #::__________ TOTAL: $_________

PAYMENT METHOD (Please Circle)	FOR OFFICE USE ONLY
Check Cash Bank Check or Money Order Credit Card	Date Rec'd:___________________________
Account Number______________________	Prepared by:
Account Number:______________________	VALIDATION
Expiration Date:______ Verification I.D.Number ______
SIGNATURE_______________________________
One form per student-Please duplicate this form if needed