BC3 Lifelong Learning: Registration Form

LIFELONG LEARNING REGISTRATION FORM Mail the completed registration form to BC3 Lifelong Learning, P.O. Box 1203, Butler, PA 16002-1203. Checks should be made payable to Butler County Community College. You will receive a registration confirmation once processed. * Indicates required field. STUDENT ID * NAME * STREET ADDRESS * CITY

* COUNTY

* HOME PHONE

* STATE

* ZIP * BIRTH DATE

WORK PHONE

* E-MAIL

□ Check box to receive emailed announcements and special offers. COURSE #

COURSE TITLE

TUITION

Registration Fee Per Semester

$2.00

Total Amount GENDER ETHNICITY

□ I prefer not to answer □ Female □ I prefer not to answer □ White □ Spanish-Surnamed Hispanic □ Asian □ Native Hawaiian or Other Pacific Islander

□ Male □ Black or African American □ American Indian or Alaskan Native

METHOD OF PAYMENT

□ Check made payable to: Butler County Community College □ Charge My: □ MASTERCARD □ VISA □ DISCOVER □ American Express Card No. Signature

Exp. Date

CVV Code