| MOHAWK I.D. | DATE OF BIRTH | SOCIAL INSURANCE NUMBER |
|---|---|---|
| (9 digits) |
/ / (DD / MMM / YYYY) |
(Collected for Income Tax purposes) |
| NOTE: Date of birth is required on the Mohawk College student information system to assist the retrieval of your academic grades from the computerized/microfilmed student files and helps to locate your student academic transcripts in the future. | ||
| CONTACT INFORMATION | |||||
|---|---|---|---|---|---|
| Dr. Mr. Mrs. Miss Ms. | |||||
| Surname: | Firstname: | Second Name: | |||
| Street Address: | Apt. #: | ||||
| City: | Province: | Postal Code: | |||
| Home Phone #: | () - | Business Phone #: | () - Ext: | ||
| COURSE INFORMATION | ||||||
|---|---|---|---|---|---|---|
| CRN | SUBJECT/ COURSE CODE |
COURSE NAME | LOC'N | START DATE mmm/dd |
FEE | |
| Course #1 | / | |||||
| Course #2 | / | |||||
| Course #3 | / | |||||
| If my choice is full, please add my name to the wait list: Yes No | ||||||
| PREREQUISITE(S) | |||
|---|---|---|---|
| Have you met the entrance requirements for the course(s) for which you are applying? (Refer to program and course details) Yes No |
Are you 19 years of age or older? Yes No | ||
| Are you a Canadian Citizen, Aboriginal or Landed Immigrant? Yes No |
Do you possess a high school diploma? Yes No | ||
| METHOD OF PAYMENT | |
|---|---|
| Certified Cheque (Not available for Fax-in registration - make enclosed cheque payable to Mohawk College) | |
Visa  MasterCard  |
Card number: - - - Expiry Date: / Signature (required for credit card payment): |
| Fax completed form to 905-575-2348 |
Mohawk College collects and retains personal information in compliance with the Freedom of Information and Protection of Privacy Act (RSO 1990). See the Privacy Statement at www.mohawkcollege.ca/legal.html