Registration Request For Noncredit Courses
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1
2REGISTRATION REQUEST FOR NONCREDIT COURSES
PLEASE ANSWER ALL ITEMS AND PRINT CLEARLY
Last Name
First Name
Middle Name
LIST PERMANENT LEGAL ADDRESS (ES
). A permanent address is one used for voting,
motor vehicle registration, income tax and other legal purposes. Must show addresses to cover at
least two years.
Number
Street
Apt. No.
City
State
Zip
FROM: mo./yr.
TO: mo./yr.
Previous address (if less than two years)
MAILING ADDRESS
(If different from legal address)
P. O. Box/Number/Street/Apt. No.
City/State Zip
FROM: mo./yr.
TO: mo./yr.
COUNTY/COUNTRY
HOME TELEPHONE
WORK TELEPHONE
______________/___________ _______________________
_________________________
Area Code + Number
Area Code + Number + Ext.
SOCIAL SECURITY NUMBER
BIRTHDATE
- (Month/Day/Year)
_ _ _-_ _-_ _ _ _
NOTE TO ALL STUDENTS: You are hereby informed that you cannot be required to provide a Social
Security Number (SSN). The SSN is used by colleges as a common method to identify student records, and is
authorized by the state chancellor’s office of the California Community College system which uses them for
evaluation of educational programs and services. If you refuse to provide a SSN, a local student I.D. number
will be assigned. Students who do not have a Social Security Number on file will be required to produce their
local student I.D. number for all current and future services. Also Public Law 104-208 known as the Solomon
Amendment requires Mt. San Jacinto College to provide student directory information to the Department of
Defense, including Military recruiters, upon request.
ETHNIC BACKGROUND
(choose only one)
□ (AA) African-American
□ (HMA) Hispanic/Mex-American
□ (AO) African – Other
□ (HAS) Hispanic/S. American
□ (AC) Asian/Cambodian
□ (HO) Hispanic/Other
□ (ACH) Asian/Chinese
□ (ME) Middle Eastern
□ (AI) Asian/Indian
□ (NA) Native American/Alaskan
□ (AJ) Asian/Japanese
□ (ONW) Other Non-White
□ (AK) Asian/Korean
□ (PACG) Pacific Islander/Guam
□ (AL) Asian/Laotian
□ (PACH) Pacific Islander/Hawaii
□ (AV) Asian/Vietnamese
□ (PACS)
Pacific Islander/Samoan
□ (ASO) Asian/Other□
□ (PACO) Pacific Islander/Other
□ (F) Filipino
□ (WHNH) White/Non-Hispanic
□ (HCA) Hispanic/Cent. American
□ (DEC) Declined to State
□
□
□
□
□
GENDER:
ADMISSION FOR
Male
Female
:
SUMMER
FALL
SPRING
□
□
ADMIT STUDENT STATUS
: (check one)
(RTS) Returning Transfer
(K10) K-10
□
□
□
th
(FTS) First Time Student
(RET) Returning Student
(11/12) 11/12
Grade
□
□
(FTTS) First Time Transfer Student
(CONT) Continuing
27
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