HCI Student Registration Form

PLEASE FILL OUT THIS FORM AS COMPLETELY AS POSSIBLE. (* REQUIRED,* RECOMMENDED)

Personal Information

Title*

Social Security #*

(Ex. 000-00-0000, Used for Identification)

First Name*

Middle Name

Last Name*

Nick Name*

(Name you go by)

Primary Email Address*

(Ex. xxx@xxx.com)

Alternative Email Address*

(Ex. xxx@xxx.com)
Home Information

Address*

Apt. #

City*

State*

(Ex. MD)

Zip Code*

(Ex. 00000-0000 or 00000)

Telephone #*

(Ex. 000-000-0000)

Fax #*

(Ex. 000-000-0000)

Web Site

Work Information

Address*

P.O. Box #

Suite #

City*

State*

(Ex. MD)

Zip Code*

(Ex. 00000-0000 or 00000)

Telephone #*

(Ex. 000-000-0000)

Fax #*

(Ex. 000-000-0000)

Web Site

Personal Background

Highest Education


If other, please specify

Computer Level*

Select Program Titles To Register*

         
 
Payment Information

Payment Plan*

No matter which payment plan you select, we highly recommend you to visit HCI at least once prior to the first class on your list starts.

If you are paying by Credit Card, you may: 

Fill out the information below (only recommended for secured connection)

Call us after you have received a confirmation (not the automated reply)

Have us call you back after your information has been processed.

(In most cases, your credit card will NOT be charged until a week before the first class starts)

Credit Card Type

Credit Card Number (Ex. 0000-0000-0000-0000)
Expiration Date (Ex. MM/YY)
Full Name On The Card

If you are paying the full amount by Cash or Check (in One Payment), you may mail it to us or drop it at HCI Office at least one week prior to the first class of the desired course. Payment Plan can be arranged. Please contact us for details.
Other Information

Hobbies/Interests

Question(s)

Comment(s)

Agreement

HCI Student Registration Form Agreement:*

By selecting "Agree" above, you agree that ALL INFORMATION provided above are true based on your knowledge. (You MUST choose "Agree" in order to register. Otherwise your information will not be processed! NO EXCEPTIONS!)

Please click the button only once. It may take up to 3 minutes to process.