Self Service Forms

Note: This form is only for students not seeking a degree from Quinsigamond Community College. Complete the form, then click the Submit button. All fields with * must be completed.

Currently, we are ONLY accepting registration forms for Fall 2 semester runs from October 28^th – December 17^th, 2019.

Registration for Intersession and Spring 2020 opens November 4^th for students who are currently enrolled and November 19^th for all/new students who are not currently enrolled.

SSN # or QCC ID#

Prefix

First

Middle

Last

Suffix

Address 1

Address 2

City

State

ZIP code

Home Phone

Cell Phone

Date of Birth

Email Address

Sex

Are you a veteran of the U.S. Armed Forces ?

Yes
No

Race/Ethnicity-Select as many as apply

Are you Hispanic/Latino ?

Yes
No

Are you a United States citizen ? If yes, go to section DOCUMENTATION.

Are you a Permanent Resident ?

Yes
No

If yes, list Alien Registration Number

If you are not a U.S. Citizen or Permanent Resident, please state your Visa or immigration status in detail including Home Country.

DOCUMENTATION : If you are a US citizen or permanent resident, select A or B or C.

I have been a Massachusetts resident for six (6) continuous months and intend to remain here. As proof of my intent to remain in Massachusetts, I possess at least 2 of the following documents, which I shall present to the institution upon request. These documents are dated within one (1) year of the start date of the academic semester for which I seek to enroll (except possibly for my high school diploma). The institution reserves the right to make any additional inquires regarding the applicant's status and to require submission of any additional documentation it deems necessary.

B. I am a member of the armed forces (or spouse or unemancipated child) on active duty in Massachusetts

Yes
No

C. I am not a Massachusetts resident. My home state is :

What Semester are you registering for

Example: ENG 101, 01, Composition I, 3

Course 1

Course Code

Section #

Course Title

Credits

Course 2

Course Code

Section #

Course Title

Credits

Course 3

Course Code

Section #

Course Title

Credits

Course 4

Course Code

Section #

Course Title

Credits

Prerequisites will be strictly adhered to. If you have taken the required prerequisite course(s) at another institution for the above selection(s), please UPLOAD a copy of unofficial transcript.

I certify that this information is true and accurate. I understand that any misrepresentation, omission or incorrect information shall be cause for disciplinary action up to dismissal, with no right of appeal or to a tuition refund.

Type in your First and Last Name as an electronic signature

Date:

Parent/Guardian Signature (Student is under 18 years old)

Jenzabar Contained Form