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: _______________