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: ______________________________
Social Security No.: __________________  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: _______________