College Program Application
Return this form with your payment to:
NJMSC ⁄ NJSG College Program, 22 Magruder Road, Fort Hancock, NJ 07732.
Name: __________________________________________________ Student ID or SSN: _____________________________
Address: ________________________________ City: _____________________________ State: _______ Zip: ______–____
Telephone: (circle) Home or Cell ___________________________________ Email: ____________________________________
College of present enrollment: _____________________________________________________________________________
Address: ________________________________ City: _____________________________ State: _______ Zip: ______–____
Current Status: (circle) F S J S Grad
NJMSC/NJSG Member Institution of enrollment (if different from above): __________________________________________________
Previous NJMSC/NJSG Registrant? (circle) NO YES If yes, when? _______________________________________________________
In event of emergency notify:
Name: ___________________________________________ Relationship to Student: ________________________________
Telephone: (circle) Home or Cell ________________________________________________________________________________
Address: ________________________________ City: _____________________________ State: _______ Zip: ______–____
I wish to reserve a seat in the following NJMSC ⁄ NJSG – hosted courses:
| Course Title | Session | Credits | NJMSC/NJSG Processing Fee Enclosed* (Credits x $25.00) |
|---|---|---|---|
| Total Fees Enclosed |
*You must enclose a check payable to the NJMSC/NJSG with this form for the total of fees incurred. This reserves your enrollment in each course requested. To receive credit for your NJMSC/NJSG–hosted course you must also register at your home institution (which must be one of NJMSC/NJSG’s Participating Member Institutions) or arrange for transfer. NJMSC/NJSG processing fee is non-refundable. Return this form with your payment to: NJMSC/NJSG College Program, 22 Magruder Road, Fort Hancock, NJ 07732.
For more information go to http://www.njmsc.org/Education/College_Programs/College_Course.html or contact NJMSC/NJSG’s Rosemary Higgins, College & Special Programs Coordinator at 732-872-1300, ext. 19.
