Registration Form Please print this web page on your printer and completely fill out all parts of the form below to register for Continuing Education Classes. You may fax your printed form to (201) 447-7861

Social Security Number Last Name First Name Middle Initial Street Address Apt. # City or Town State Zip Code Country Home Telephone with Area Code Business Telephone with Area Code E-mail Address Federal Reporting Both the State and Federal Government require that we submit information on our student's characteristics. Your response to this section is voluntary, but will help us to implement our affirmative action policy. BCC is an equal opportunity institution. This information does not affect admission or placement. Have you ever taken a BCC Continuing Education Course?     Yes No Sex Male Female Race Education Reason Attending How did you hear about the program? Black, non-hispanic Less than high school Enrichment Friends American Indian High School Certificate/CEU Previous Course Asian or Pacific Islander College College Prep Work Hispanic Associate's Degree Update Skills Newspaper Caucasian, non-hispanic Bachelor's Degree New Career Other Non-resident alien Master's Degree Recreation   Other Doctorate Consumer         Education       Course # Class # Course Title Start Date Day (Circle) Cost         M  T  W  Th  F  S           M  T  W  Th  F  S           M  T  W  Th  F  S           M  T  W  Th  F  S     Total   Visa/MC # Exp. Date Signature (as name appears on card) Please make checks payable to BERGEN COMMUNITY COLLEGE MAIL REGISTRATION FORM TO: Bergen Community College Division of Continuing Education 400 Paramus Road Paramus, NJ 07652-1595 NOTE: With this application you are registered. Unless notified to the contrary, please report to your first scheduled class. NO CONFIRMATIONS WILL BE SENT. REFUND POLICY: A student who withdraws three working days before a class begins will receive a full refund. NO REFUNDS WILL BE GIVEN THEREAFTER. ALL REFUND REQUEST MUST BE IN WRITING.