Mail-In or Fax Registration Form
Complete this registration form and:
Mail To
Eastern Iowa Community College District
Attn: Registration
306 West River Drive, Davenport, IA 52801
OR
Fax To
Clinton Community College - (563) 244-7053
Muscatine Community College - (563) 288-6116
Scott Community College - (563) 441-4053
Send a check or money order (no cash please) with the class number(s) and student's social security number written on the lower left hand corner. We will call you to confirm faxed registrations.
Tuition and fees are due at time of registration. Refunds will be issued if you cancel your registration seven days prior to the start of a class.
Name: ______________________________________________________________________________
Company Name or Vendor number: _____________________________________________________
Address: ____________________________________________________________________________
City/State/Zip Code: ___________________________________________________________________
Day Phone: _______________________________
Night Phone: ______________________________
Date of Birth: __________________
Pro. License No. (if applicable): ____________________
E-mail Address: ______________________________________________________________________
Class Title: ___________________________________
Class No. ________
Tuition/Fee: $________
Class Title: ___________________________________
Class No. ________
Tuition/Fee: $________
Class Title: ___________________________________
Class No. ________
Tuition/Fee: $________
Class Title: ___________________________________
Class No. ________
Tuition/Fee: $________
Total: $________
Make checks payable to "Eastern Iowa Community College District" or use your Credit Card.
Please charge all fees to (check one):
Mastercard___
VISA___
American Express___
Discover___
Credit Card No. _______________
Name on credit card (please print): ____________________________
Expiration Date: __________
Signature: _____________________________________________________
Date: _______________
I have read and understand the registration and refund procedures for Continuing Education.
Signature: _____________________________________________________
Date: _______________