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    Merrillville Adult Education
    Continuing Education
    Class Registration Form
     
     
    Classes:   _______________________________________________________________________
     
                    ______________________________________________________________________
     
                   ______________________________________________________________________
     
    Name:
    Address:
    City, State, Zip:
    Work Phone:
    Home Phone:
    Course Code Number:
    Section:
    Course Title:
    E-Mail Address:

    Check Number: (payable to MCSC) - Please include Driver's License Number on check


    Fee:
    VISA Number:
    MasterCard Number:
    Expiration Date:
     
    To complete the registration, please sign below if paying by credit card.
     
    Name of Cardholder:  ___________________________________________________________
Last Modified on May 13, 2011