Registration Request Form

(Please cut along dotted lines & mail to: Augusta Adult & Community Education,

33A Union Street, Augusta 04330) Please print:

Name (Last)_____________________ (First)____________ Date________

Address_______________________________________________________

Phone (work)___________________ Phone (home)____________________

Course Name Night* Fee

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

*Please indicate night, if offered more than one night. Check if senior citizen discount o

______________________________ __________ __VISA __MC__Debit

Credit/Debit Card number Expiration Date

______________________________ ______________________________

Print card holder’s name Signature (for credit/debit card users only)

For office use only

Make your check payable to:

Augusta Adult Education

Total Enclosed: $_________________