Non-Degree-Seeking Registration

Semester*Select semester you are registering for

First Name*

Middle Initial

Last Name*

Other Name(s) Used

SSN*Enter Social Security Number

Address1*Address1

City*City

State*State

Zip*Zip

Phone*

E-mail Address*

Emergency Contact Name and Phone Number*Enter Full name and phone number of emergency contact

Date of Birth*

GenderEnter your gender

EthnicityEnter your ethnicity

County of Residency Ex. Essex, Franklin

High School Name*Enter High School Name

Graduation Year*Graduation Year

Have you ever enrolled for credit courses at NCCC?

Yes

No

Have you ever been dismissed from a college for disciplinary reasons?

Yes

No

Have you ever attended another college?

Yes

No

Name of college and degree earned if any.

Citizenship*Select country of residence

If "Other" please enter Country name.Country of residence

For the next section, please enter Dept Code, Course Number, Section Letter, Days, Times, Building/Room and Credits (separated by a comma). Enter one line for each course you want to take.

Each entry for a course should look something like this:

ENG, 102, T, MW, 8am-9am, DL, 3
MAT, 105, T, MW, 10am-11am, DL, 3
SOC, 101, T, F, 9am-12pm, TI-102, 3

Course Selection*Enter course information here

Total Credits*Enter the total amount of credits registered for

Payment Method

I would like to pay online

I would like to pay by check-by-mail

I would like to make payment arrangements

If online payment or check-by-mail is chosen, you will receive an e-mail with instructions on how to proceed after submitting request.

Verification

I am the individual requesting to be registered for the courses listed above.

I understand, that by signing this registration form, I am formally registered for the above indicated semester and have incurred a financial obligation to pay for these courses unless I formally drop the courses in writing prior to the start of the semester. I understand I will need to obtain a Certificate of Residence from my home County Treasurer’s Office within 30 days of the start of classes to receive In State Tuition.

Signature*Enter your full name - Parent/guardian signature if registrant is under 18 years of age.

Date*Enter today's Date