Act 48 Credit Enrollment Form

Visiting Student Registration Form
for Act 48 Credit

Name:

Former/Maiden Name:

Address:

City:

State:

County:

Zip Code:

Date of Birth:

Social Security Number:

Gender:

Male Female

Telephone (day):

Telephone (evening):

Telephone (cell):

Email address:

Are you a US Citizen?

Yes No

Country of Birth?

Resident Alien Number:

Visa Status:

Occupation:

Business Name:

Business Address:

Business Phone:

Employer Tuition Reimbursement Plan

Yes No
%paid minimum grade required:
If yes, payment is made before after semester

How did you first hear about Cedar Crest College?

Please list your current certification:

I am registering for Courses for the :

term