CONTRACT

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CHESAPEAKE COLLEGE REGISTRATION FORM

Continuing Education and Workforce Training

Chesapeake College, P. O. Box 8, Wye Mills, MD 21679

(INFORMATION MUST BE COMPLETED IN ORDER TO PROCESS REGISTRATION)

Social Security No: Phone Home: Work

Name:

Last First Middle

Address:

Street City State Zip County Residence

Date of Birth: Sex: F M Racial/Ethnic Origin: (Circle One)

01 Hispanic

02 African American

Senior Citizen: Yes No 03 Native American

(60 or older) 04 Asian

05 Caucasian

06 Foreign

Contract Name

Contract Address

I certify that I am a legal resident of County, Maryland.

COURSE INFORMATION

Dept. No Section Course Title Tuition/Fee

CEX 031 AA Art & Science of Six Sigma $650

Student Signature Date

Chesapeake College is an equal opportunity institution.