REGISTRATION FORM


Name ______________________________________
PRINT

Signature ___________________________________

SSN ______-____-_______ DOB ____-____-_______
(SSN is voluntary and is used for records identification purposes only.)

Race/Sex (circle) Male Female
White Hispanic African-American Asian Indian
Other (specify) ______________

Address ____________________________________

City/State/Zip ________________________________

County _____________________________________

Home Phone ________________________________

Work Phone _________________________________

E-Mail Address ______________________________

Education (highest grade completed or degree earned)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 GED
Place of Employment _________________________

Status (circle one) Full time Part time Retired

Class Title Days Fee


Amount Enclosed $________________________
(Check or money order only. No cash please.)

Visa/MasterCard # _________________________

3 digit number on back of card ______________

Expiration Date ___________________________

Signature ________________________________
Make checks payable to: MCC
Mail to: MCC Continuing Education Dept.
1011 Page St., Troy, NC 27371
Phone: 910-576-6222, ext. 253 Fax: 910-576-5162