Scribd
Upload
28 views

Ccac Registration Form: Central E-Services

This document is a registration form for the Community College of Allegheny County (CCAC). It requests basic student information such as name, address, date of birth, citizenship status, residency, veteran status, and contact information. The form also asks students to select the preferred CCAC location and provides a list of locations. Additionally, it collects optional demographic information and asks students to provide their program code and course details for registration including subject, course number, section, credits, days/times. Signatures of the student and advisor are required.

Uploaded by

Bradley Jonathan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
28 views

Ccac Registration Form: Central E-Services

This document is a registration form for the Community College of Allegheny County (CCAC). It requests basic student information such as name, address, date of birth, citizenship status, residency, veteran status, and contact information. The form also asks students to select the preferred CCAC location and provides a list of locations. Additionally, it collects optional demographic information and asks students to provide their program code and course details for registration including subject, course number, section, credits, days/times. Signatures of the student and advisor are required.

Uploaded by

Bradley Jonathan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

CCAC REGISTRATION FORM

You can also register online at CCAC Central e-Services.

Check Preferred Location

Allegheny

Boyce

North

South
Homewood-Brushton Center
Braddock Hills Center
West Hills Center
Bethel Park Center

Washington County Center

CCAC

CENTRAL
e-Services

Social Security number required, if not already submitted.

Student Identification Number


Last Name

First Name

Middle Initial

Street Address

Apt.

City

State

Home Phone

Zip

Alternate Phone

County
Email Address

Date of Birth (Month/Day/Year)


Citizenship Status (Check one)

United States Citizen

Resident Alien

Non-Immigrant Visa holder/International Student

Non-immigrant Alien
Residency Status (Check one) Domicile shall mean a persons true, fixed and permanent home, to which one intends to return after being absent.

In Allegheny County

Out of Allegheny County with Community College

Out-of-state
Are You a Military Veteran?

No

Veteran Benefits:

1606 Reserve

30 Montgomery

Are You a Dependant of a Veteran?

Yes (See below)


35 Dependent

Vietnam Veteran

Disabled Veteran

No

Yes (see below)

Chapter 33 Post-9/11 GI Bill

VEAP Chapter 32

Chapter 31

Voluntary Information (Please check one in each section)


Providing the information below is optional. This voluntary information is used to comply with federal reporting and has no effect on admission to the college.
Ethnicity and Race
Hispanic/Latino/Spanish origin

No

Yes
Select all that apply:

American/Alaskan Native

Asian
Marital Status
Sex

Married

Single

Male

Female

Black or African American

Native Hawaiian or Pacific Islander

My Program is

White

Other

with Code

Student Signature

Location

Date
Term

Catalog Course No.

Section

Audit

Course Title

Credit Days
U

Time
From

To

If you are registering for an Online Learning course, visit dlsupport.ccac.edu/gettingstarted.


Advisor Comments
Advisor Signature

Date

Student Signature

Date

Registration is not complete until payment is made in full (grants, scholarships and anticipated loans; self-payment, tuition payment
plan [spring & fall only], sponsorship or any combination).
I understand that once I register I become responsible for all charges incurred, unless I drop during the designated refund periods.
I also understand that the college is extending credit to me and permitting me to register, enroll and attend classes in return for my
promise to pay the college all tuition and fees incurred as a result of my attendance and that such extension of credit constitutes an
educational loan or educational benefit that is non-dischargeable under Section 523 (a)(8) of the United States Bankruptcy Code.
The college is subject to provisions of and complies with the Family Educational Rights and Privacy Act of 1974. A statement of the college policy can be found in the student handbook and college catalog.

Revised: April 1, 2011

You might also like