REGISTRATION FORM

*Mail/bring completed form to: Student/User ID #:_____________________________

Northern Virginia Community College (required)

Office of Continuing Education – CE 202 Birth Date: ___________________________________

8333 Little River Turnpike

Annandale, VA 22003-3796 Home Phone: ( ) ____________________________

Day/Work Phone: ( ) ___________________________

NAME________________________________________________________________________________________

(Last) (First) (M.I.)

ADDRESS_____________________________________________________________________________________

(Street) (Apt #)

______________________________________________________________________________________________

(City) (State) (Zip Code)

Current E-mail Address:________________________________________________________________

(Used only for class-related notification purposes.)

(See course example in color below.)

	Course Prefix	Course Number	Section Number	Course Title	Course Dates	FEE
EX	ARTS	1532	01N	Painting with Watercolor	5/31 – 6/28	$135
1.
2.
3.
4.
5.

*Employer’s Federal I.D. #: ________________________________________________

(For tuition assistance billing and refund purposes only)

OFFICE USE: Reg. Processed: Date ______ Time ______ Initials _______ Service Indicator ______

NOTE: Payment is required at the time of registration. Please enclose your check or money order (payable to NVCC) or complete the credit card information below. Cash payments should be made to the Annandale Campus Business Office in CG 220. The Continuing Education Office in CE 202 will accept payments when the Business Office is closed. If you have questions, please call us at (703) 323-3168.

If you prefer to fax your registration, please complete the information below in black ink.

Fax # : (703) 323-3399

Credit Card # (VISA, MasterCard or American Express):_____________________________________

Expiration Date: ___________

Signature: _______________________________________________________

Check/Money Order enclosed _______