Phone Registration: 978-556-3700

Payment Instructions: Mail to NECC, Life Long Learning Office, TC-122, 100 Elliott Way, Haverhill, MA 01830. Check, money order, Mastercard, VISA and Discover payment acceptable. Please write your Social Security number on the face of your check.

Non-Credit Refund Policy: 100% of the tuition cost and materials fee for noncredit courses dropped the business day prior to the class. 50% of the cost of courses dropped the business day prior to the second class. The materials or some course fees (if any) are not refunded for a course dropped on or after the first meeting of the course. See www.necc.mass.edu for more information.

Social Security Number ______-____-________


Last Name____________________ First Name______________ M. Int.____


Date of Birth ____/____/____

Mailing Address_________________________________________
                                           Number and Street, City, State, ZIP

Legal Address __________________________________________
                                           Number and Street, City, State, ZIP

Home Phone (____)-______-______


Work Phone (____)-_____-______

You may charge your courses: We accept MasterCard, Discover and VISA for Payment of costs. Complete all items below. Note: Refunds are made by check


__________________________ MasterCard, Discover or VISA Account No.

__________________________ If MasterCard, 4-digit number below Account No

__________________________ Expiration Date

__________________________ Amount Authorized

__________________________ Print your name on this line

__________________________ Your Signature and date