Printable Registration Form

Complete this registration form and:

Mail To
Eastern Iowa Community College District
Attn: Registration
306 West River Drive
Davenport, IA 52801

OR

Fax To
Clinton Community College - 563-244-7053
Muscatine Community College - 563-288-6116
Scott Community College - 563-441-4053

Send a check or money order (no cash please) with the class number(s) and student's social security number written on the lower left hand corner. We will call you to confirm faxed registrations.

Tuition and fees are due at time of registration. Refunds will be issued if you cancel your registration three days prior to the start of a class.

Name:___________________________________________________________________________

Company Name or Vendor number: ____________________________________________________

Address: _________________________________________________________________________

City/State/Zip:_____________________________________________________________________

Day Phone: _____________________________________

Night Phone: ____________________________________

Social Security No. _______________________________

Prof. License No. (if applicable): _____________________

E-mail Address:_________________________________________________

Class Title: ______________________________________ Class No.  ___________ Tuition/Fee: $________

Class Title: ______________________________________ Class No.  ___________ Tuition/Fee: $________

Class Title: ______________________________________ Class No.  ___________ Tuition/Fee: $________

Total: $ ________


Make checks payable to "Eastern Iowa Community Colleges" or use your Credit Card.

Please charge all fees to (check one):

Mastercard____ VISA____ American Express____ Discover____

Credit Card No. _____________________________________

Name on credit card (please print):
____________________________________________________

Expiration Date: __________

Signature: __________________________________________

Date:  ______________________________________________

I have read and understand the registration and refund procedures for Continuing Education.

Signature: __________________________________________

Date:  ______________________________________________