Business/Industry and Continuing Education Online Regstration

(Registration Phone Number)
Continuing Education: 1-888-336-3907
Clinton Community College: (563)244-7100
Muscatine Community College: (563)288-6100
Scott Community College: (563)441-4100

Printable Mail-In or Fax Registration Form

Note: EICCD does not maintain a secure server connection. You can complete this form, select the submit button and your information will be automatically received by our registration department. You will then need to mail in your payment separately. Please note the course number on your check. If you prefer, you can also complete this form, print it out and mail it in with your payment. For more information call 1-888-336-3907 (toll free).

PLEASE NOTE:
Be sure to print out the next screen to have a copy of this form for your records.

*Required fields.

First Name:*

Last Name:*

For Companies:
Add any additional names in the "Comments" box below.
The names below will be the company contact person.

Company Name or Vendor number:

Address:*

City:*

State: Zip:*

Day Telephone:*
(Please include your area code)

Night Telephone:
(Please include your area code)

E-mail:

Pro. Liscense No.:
(If applicable)

	Class No.:	Tuition/Fees:	Class Title:
*1
2
3
4
5

Payment Plan:*
(Please check one)

Mail in a check
Company Billing
Will call with credit card number

Comments:

For Individuals
Make a check with the class number(s) and student's SS# written on the lower left hand corner, payable to Eastern Iowa Community College District (EICCD)

Send check or money order to:
Eastern Iowa Community College District
Attn: Registrar
306 West River Drive
Davenport, IA 52801
Or call 1-888-336-3907 to give us your credit card information.
No cash please.

For Company Billing:
For each student include (in the Comments Box above) name. Also include the total amount due in step #11 above.

Registration and Refund Procedure: All tiotion and fees must be recieved by the published "fees due" date to ensure your registration in the class. Registration and fees are accepted after this date if space exists in the class. Refunds are made only if you cancel your registration in a class prior to the published "fees due" date.