IMPORTANT: Both pages must be completed.

PAGE 1of 2

REGISTRATION FORM FOR

ID #___________________________
CREDIT COURSES
Last Name______________________ First Name_____________________ Phone______________________

SEMESTER WHAT ARE YOUR EDUCATIONAL GOALS?

(Registering for) ■ QCC Associate’s Degree
■ Fall ■ QCC Certificate
■ Spring ■ Enhance work skills, without receiving a degree
■ Summer I ■ Take courses to qualify for another QCC Program of Study
■ Summer II ■ Completing course for interest, without receiving a degree
■ Intersession ■ Transfer courses to another institution, without receiving a degree
■ Taking courses while considering educational options

FIRST CHOICE SELECTIONS

Course # Sec. # Course Title Day & Time Room Instructor Cr.
XXX 101 12 Intro to Psychology (sample) MWF 9-9:50 123S J. Smith 3

FOR MAIL/FAX REGISTRATION

Prerequisites will be strictly adhered to. If you have taken the required prerequisite course(s) at another Institution for the above
selection(s), please indicate below where the course was taken.
Course (Please include copy of transcript.): ________________________________________________________________
Number and title:______________________________________________________________________________________
Completed at: ________________________________________________________________________________________

INSTRUCTIONS PERSONAL INFORMATION:

Make full payment by check, money
order or MasterCard/ Visa payable to Student’s Signature _________________________________Date __________
Quinsigamond Community College.
Advisor’s Signature _________________________________Date __________
MAIL TO:
Registrar’s Office, Box 9 FULL PAYMENT IS REQUIRED WITH THIS FORM.
Quinsigamond Community College Payments can be made by check payable to QCC or credit card (MasterCard,
670 West Boylson Street Visa, Discover) over the phone at 508-854-4560.
Worcester, MA 01606
For returning students, payments can also be made online via The Q (our
FAX TO: 508-854-4456 Student and Faculty Portal). Students who fail to pay may have their
class schedule cancelled.

Quinsigamond Community College, 670 West Boylston Street,Worcester, MA 01606-2092

(508) 854-4257 • fax (508) 854-4456 • www.qcc.edu
 IMPORTANT: Both pages must be completed. PAGE 2 of 2
REGISTRATION FORM FOR CREDIT COURSES
PERSONAL INFORMATION: PLEASE PRINT
______________________ First Name ______________ Middle Initial __
Last Name

__________________________ _________________ ____ ________

(Street Address) (City) (State) (Zip Code)

SSN# or Student ID __________________________ Date of Birth ___/___/___ Sex: __ Male __ Female

Please answer questions 1 and 2 below:

1. Are you Hispanic/Latino? ■ Yes ■ No
2. Race/Ethnicity–Select as many as apply: ■ American Indian/Alaskan ■ Asian ■ Black/African American ■ White
■ Native Hawaiian or other Pacific islander ■ Nonresident alien ■ Other___________________________

Home Phone _____________ Cell Phone _____________ Work Phone _____________

E-mail ______________________________________________________

■ Required Information - please select ONE of the following three options:

1. Are you a United States citizen? ■ Yes ■ No If not, please complete the following:
or
2. Are you a Permanent Resident? ■ Yes ■ No (If yes, list alien registration number: ______________________)
or
3. If you are not a U.S. Citizen or Permanent Resident, please state your Visa or immigration status in detail:________________
______________________________________________________________________________________________________

■ Required - IF YOU ARE a US citizen or permanent resident, answer 4A or 4B or 4C or 4D.

4A. ■ I have been a Massachusetts resident for six (6) continuous months and intend to remain here.
As proof of my intent to remain in Massachusetts, I possess at least 2 of the following documents, which I shall present to the institution upon request.
These documents* are dated within one (1) year of the start date of the academic semester for which I seek to enroll (except possibly for my high
school diploma). The institution reserves the right to make any additional inquiries regarding the applicant’s status and to require submission of any
additional documentation it deems necessary. Please check-off those documents you possess as proof of your intent to remain in Massachusetts.
■ Valid Driver’s license ■ Utility bills* ■ Employment pay stub*
■ Valid Car registration ■ Voter registration* ■ State/Federal tax returns*
■ Mass. High School Diploma ■ Signed lease or rent receipt* ■ Military home of record*
■ Record of parents’ residency for unemancipated person* ■ Other ________________
4B. ■ I am an eligible participant in the New England Board of Higher Education’s Regional Student Program.
4C. ■ I am a member of the armed forces (or spouse or unemancipated child) on active duty in Massachusetts.
4D. ■ I am not a Massachusetts resident as defined in 4A.

■ CERTIFICATION
I certify that this information is true and accurate. I understand that any misrepresentation, omission or incorrect information shall be
cause for disciplinary action up to dismissal, with no right of appeal or to a tuition refund.
Student Signature: __________________________________________________________________Date ______________________
Parent/Guardian Signature (Student is Under 18 Years Old): ________________________________________Date ______________________

FOR OFFICIAL USE ONLY — DO NOT WRITE IN THIS BOX

I have reviewed the above information in order to determine the individual’s eligibility to receive the in-state tuition rate. Based
on my review, I have determined that this individual:
■ IS eligible for the in-state rate
■ IS NOT eligible for the in-state tuition rate
■ I am not able to make the determination at this time.The following information has been requested of the applicant:
__________________________________________________________________________________________________________

Authorized College Personnel:______________________________________________Date:_______________________________