College Student Registration Form (Page 2 of 2) in pdf

Student REGISTRATION FORM |

Part 2 of 2

Name _____________________________________________________________ Student ID# _________________________________

NOTE: If you are registering for a course that requires a prerequisite(s) and you took the course at another institution, you must provide

proof (unofficial transcript, grade report) of successful completion of the prerequisite course. If you have not successfully completed

the prerequisite course(s), you must obtain the course instructor’s permission (signature or email) in order to register.

Your enrollment in the course(s) below is subject to availability at the time your registration form is processed.

Course Name/Number

Credits

Section

Sub Type

Audit

Instructor Signature

Instructor approves that the student may register for the course

sample: ENGL 101

MO1

LEC

without the prerequisite.

Student Agreement:

I agree to abide by all College/campus rules and regulations.

Immunization Requirement:

Students registering for six credits or more and

I agree to pay TC3 for tuition and fees and any reasonable collection costs if applicable.

born on or after January 1, 1957 must provide proof

of MMR immunization to the TC3 Health Center.

Student Signature: ______________________________________________________ Date: _______________

Call 607.844.8222, Ext. 4487 for more information.

Advisor Signature: _______________________________________________________Date: _______________

METHOD OF PAYMENT:

If proof of residence is not provided in the time required, you will be liable for the nonresident tuition.

REFUND POLICY: If you drop a course or withdraw from the College,

Check

Money Order

Credit Card

you will be charged non-refundable tuition, fees, housing and meals

Payable to: Tompkins Cortland Community College

according to the following schedule for 15-week courses.

To pay by credit card

FALL AND SPRING SEMESTERS

*Non-refundable charges will be

complete the following:

MasterCard

Visa

Discover

prorated on a similar schedule for

Prior to the start of classes ..................0%

courses less than 15 weeks. Payments

During the first week of classes .........25%

Credit Card #:___________________________________________________

in excess of final liability will be refunded

During the second week of classes....50%

to the student. Non-payment of tuition

During the third week of classes........ 75%

Exp. Date: _______________________

and fees does not constitute an

After the third week of classes .........100%

automatic withdrawal.

Cardholder Name

(print as appears on card)

SUMMER AND WINTER SEMESTERS

On or before the last date to drop

a course..................................................0%

__________________________________________________________________

After the last date to drop a course...100%

Address of Cardholder

(where you receive your credit card statements)

BY MAIL

Street Address or PO Box: _________________________________________

Payment must be included. Once we receive and process your registration

form, a class schedule and receipt of payment will be mailed to you.

_______________________________________ City:______________________

MAIL TO: TC3, Enrollment Services Center • P .O. Box 139

170 North Street • Dryden, NY 13053-0139

State:_____________

Zip:__________________

BY FAX

Cardholder Telephone(s): (home)__________________________________

Payment must be made by MasterCard, Visa, or Discover.

FAX TO: 607.756.7562 or 607.844.6541

(cell) _____________________________________________________________

IN PERSON

Cardholder Email: _________________________________________________

Payment must be provided at time of registration.

DRYDEN: Room 215 170 North Street 607.844.6580

ITHACA: 118 North Tioga Street 607.272.3025

Cardholder Signature: _____________________________________________

CORTLAND: 157 Main Street 607.756.5275

College Student Registration Form Page 2

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