Registration:
________________________________________
Name of Course Attending
________________________________________
Name
________________________________________
Social Security Number
________________________________________
Title / Position
________________________________________
Organization
________________________________________
Street Address
________________________________________
City, State, Zip
________________________________________
Phone, Fax
________________________________________
E-mail
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Method of Payment:
Make checks payable to Montcalm Community College
Check enclosed for $__________
PO # ___________________________________
I authorize Montcalm Community College to charge $__________ to my:
___Visa ___MasterCard ___Discover
_______________________________________
Credit Card Number
_______________________________________
Expiration Date
_______________________________________
Signature
_______________________________________
Name as it appears on credit card bill (Please Print)
Mail or Fax to:
M-TEC
1325 Yellow Jacket Drive
Greenville, MI 48838
Fax: (616) 754-4587
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