SCOPE REGISTRATION FORM  (Bayport/Blue Point)

Last Name ____________________________________  First ______________________________

Phone (Bus.) _________________________ Phone (Home) ________________________________

Street ________________________________________________ Town ______________________

Course __________________________________________ Section _________________________

Instructor _____________________________________ Day _____________  Hour _____________

Starting Date ____________________________

School District Resident? (please check)  ________ Yes  _________ No

Non-Resident Fee $ __________ Course Fee $ ____________ Total Fee Pd. $ _________________

(Office Use Only: Budget Code: ______________ Payment Received: ___________________)

I wish to pay by credit card:  We accept MasterCard, Visa, American Express & Discover

Cardholders Name: _________________________________________________________________

Credit Card Number _________________________________________________________________

Expiration Date: _____________________________  Total Amount Charged: ___________________

Signature of card holder: ____________________________________________________________

ALL CHARGES WILL APPEAR AS SCOPE ON YOUR CREDIT CARD BILL.

For Office Use Only: Budget Code: 859

             Assume you have been accepted in the course unless notified otherwise.