SCOPE APPLICATION Bluepoint

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.