Jenzabar University

Note: This form is only for Massachusetts Inclusive Concurrent Enrollment Initiative (MAICEI) students. Complete the form, then click the Submit button. All fields with * must be completed.

SSN # or QCC ID#

Prefix

First

Middle

Last

Suffix

Address 1

Address 2

City

State

ZIP code

Phone

Date of Birth

Email Address

Sex

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

Race/Ethnicity-Select as many as apply

Are you Hispanic/Latino ?

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

Are you a Permanent Resident ?

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.

Please check-off those documents you possess as proof of your intent to remain in Massachusetts

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

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

What Semester are you registering for

Course Code

Section #

Course Title

   Credits

Course Code

Section #

Course Title

   Credits

Course Code

Section #

Course Title

   Credits

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)