Georgian College

5 REGISTER NOW – 705.722.1516 OR 1.888.812.7511 marinetraining.ca COURSE REGISTRATION FORM (PLEASE USE ONE REGISTRATION FORM PER STUDENT) COURSES REQUIRED (Please use one form per student) Course name Course code Course date Course fee Total fees Your student number (from previous Georgian College courses) PERSONAL INFORMATION Last name First name Middle name/initial Street address Apt. # City Province Postal code Phone Cell phone Date of birth – YYMMDD Email address CDN # Employer Please indicate if you will be seeking funding from HDSDC: Yes No Company paid (if "yes" an authorization letter must be attached): Yes No FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT The information on this form is collected under the legal authority of the Ministry of Colleges and University Act, R.S.O. 1980, Chapter 272, 5.5; R.R.O. 1980 Regulation 640. The information is used for administration and statistical purposes of the College and / or the Ministries and Agencies of the Government of Ontario and the Government of Canada. For further information, please contact the Office of the Registrar at the address and telephone number listed on this page. I certify that the above information is true and complete. I understand that any false or incomplete information submitted in support of my application may invalidate my application. I have read the Freedom of Information and Protection of Privacy Statement (see above). I hereby authorize the release of information contained herein to my employer ( if company paid) or Service Canada (if funded). Please note that this form, once signed, will provide the academic authority to register students in the above courses and sections. Signature Date (MM/DD/YYYY) PAYMENT INFORMATION VISA American Express MasterCard Certified cheque Money order Credit Card # Expiry date (MM/YY) Name on card Signature Please mail this form to: Please make certified cheque or money order payable to Georgian College. Georgian College C170 – Registrar's Office – Marine Registrations One Georgian Dr. Barrie ON L4M 3X9 or fax to: 705.722.5118

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