ISE Online Registration Form

Name (Required)

Soc.Sec.No. (Required)

Date of Birth:

/mm/dd/yyyy:

Male/Female

Male
Female

Address: (Required)

City/State/Zip: (Required)

Day Phone: (Required)

Evening Phone: (Required)

Fax Number:

Your E-Mail Address (Required)

Ethnic Origin:

Please check categories that apply. Response is voluntary and information will be kept confidential. Refusal to provide this information will not be subject to any adverse treatment:

American Indian/Alaskan Native
Black/Non Hispanic
Hispanic
White/Non Hispanic
Haitian
Asian or Pacific Islander
Other

Other:

Ethnic Origin: Other

Have you ever been convicted of a felony?

Yes
No

Have you ever been dismissed from college for disciplinary reasons?

Yes
No

Felony/Disciplinary: A felony in New York State law is defined as a crime for which more than one year in prison may be imposed. The felony question applies if you have been convicted as an adult. I hereby certify that the above statements are true and correct to the best of my knowledge.

If you answer yes to either question you will receive a letter requesting further information. Answering yes to either question does not automatically bar an applicant from admission. A campus committee will then review information provided. You must answer this question. Failure to do so will suspend the processing of your application.

Course Number -1 (Required)

Course Title/Date - 1 (Required)

Fee - 1 (Required)

Course Number - 2

Course Title/Date - 2

Fee - 2

Course Number - 3

Course Title/Date - 3

Fee - 3

Total Fees:

Please charge my (Required)

VISA Card
MasterCard
Discover Card

Account No. (Required)

Expiration Date: (Required)

Card Security code: (Required)

(3-digit code on back of card):

Card Holder Name:

(If different than above)

Guarantee

If you are not satisfied with a continuing education course, SUNY Rockland Community College will refund your fee or transfer it toward another continuing education course. You must notify the registration clerk prior to the second meeting of the course or prior to the afternoon session of a one-day seminar. Job Training, Health Professional courses and trips have a separate refund policy.

See the SUNY Rockland Community College catalog for refund policies for academic credit courses.

Sections

Personal tools

Guarantee