Fisher College Continuing Education

Fisher College Continuing Education
Registration Form

Last Name:

First Name:

Middle Name:

Social Security Number:

Mailing Address:

E-mail:

City:

State:

Zip:

Country:

Date of Birth:

Sex:
____ Male ____ Female

Home Phone:

Work Phone:

Program of Study*

Choose One
____ Degree ____ Certificate

Date you plan to start your program:

Are you a U.S. Citizen:
____ Yes ____ No

If not: Country of Birth:

Country of Nationality:

If not a citizen, what will your immigration status be while at Fisher?
____ Perm. Resident ____ Student (F1 Visa) ____ Other Specify

Are you a Veteran?
___ Yes ____ No

Employer's Name:

Does your employer have a tuition reimbursement Policy?
____ Yes ____ No

Employers Address:

High School Attended*

City

State

Graduated*: ____ Yes ____ No Year: ________

GED*: ____ Yes ____ No Year: ________

College(s) Attended	Date(s) Attended

Have ou ever attended Fisher before? ____ Yes ____ No	If yes, what location(s)	Date(s)	Name Attended Under

In case of emergency, please notify:

Relationship:

Phone:

Course Selection - Term ____ 1 ____ 2 ____ 3 ____ 4 ____ 5 ____ 6

Course Number

Course Title

Campus

Time

Days

Cost

___ Days	___ Eves.
___ Online

___ M/W	___ T/TH
___ SAT

___ Days	___ Eves.
___ Online

___ M/W	___ T/TH
___ SAT

___ Days	___ Eves.
____ Online

___ M/W	___ T/TH
___ SAT

___ Days	___ Eves.
___ Online

___ M/W	___ T/TH
___ SAT

Method of Payment

___ Check (to be mailed)

___ Industry Sponsor _______________________________________ (enter business name)

___ Financial Aid (complete at campus)

___ Loan (on account at campus)

___ Other _________________________________________(specify)

Credit Card

___ Visa

___ MasterCard

___ Discover

Account Number _____________________________

Expiration Date ______________

Mail, Fax or hand deliver to:

North Attleboro 451 Elm Street North Attleboro, MA 02763 (508) 699-6200 Fax: (508) 643-9461 Chair of DCE Programs, N. Attleboro: Jude Tomasino infoattleboro@fisher.edu	Boston 108 Beacon Street Boston, MA 02116 (617) 536-4647 Fax: (617) 236-5462 Chair of DCE Programs, Boston: Pauline Hatzikostantis infoboston@fisher.edu
New Bedford 777 Church Street New Bedford, MA 02745 (508) 998-3254 Fax: (508) 998-5632 infonewbedford@fisher.edu	Fisher Online 451 Elm Street North Attleboro, MA 02763 Phone: 508-695-4324 Toll-Free: 1-866-309-6539 Fax: 508-695-4604 Dean of Online and Professional Education: Janet Harrington Director: Jude Tomasino fisheronline@fisher.edu