ACE: ACE Registration Form

Adult and Continuing Education
Registration Form

Print this form, then Mail or Fax it:

LaGuardia Community College Room M141
31-10 Thomson Ave.
Long Island City, NY 11101
Fax: (718) 609-2074

E-Mail:

______________________

Registration for ______________Semester.

(  ) I am enclosing a check or money
     order
(  ) I want to pay with my Credit Card

Credit Card (check one):
American Express
Discover
MasterCard
Visa

Name of Card Holder:

_________________________________

Expiration. Date: ____/______ (mm/yy)

Credit Card Number:
______________________________________

_________________________________

Signature

Social Security Number:

________-_____-________

Date of Birth:

_____/_____/_____

Last Name:

__________________________

First Name:

__________________________

Street Address:

_______________________

__________________________

City:

__________________________

Zip:

__________________________

Home Telephone:

(____) ________-____________

Business Telephone:

(____) ________-____________

Ethnic Background:

( ) Black non Hispanic
( ) White non Hispanic
( ) Hispanic
( ) Asian-pacific Islander
( ) American Indian-Native
( ) Alaskan
( ) Other _______________________

COURSE CODE

SECTION

COURSE TITLE

COST

________

_____

______________________________________________

_______

I authorize LaGuardia Community College to charge the following amount to my credit card for registration of the above course/s.

Registration Fee:

Other Fees:

TOTAL:

$12.00

________

_______

Adult and Continuing Education Registration Form

Print this form, then Mail or Fax it:

Adult and Continuing Education
Registration Form