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MAIL TO: 
Edmonds Community College 
Business Training Center 
3008 100th ST SW 
Everett, WA 98024 
OR FAX TO: (425) 267-5749 
OR EMAIL TO: btc@edcc.edu 

BTC WATR Registration
 Student Name     Last: (Surname):      First:      M.I.: 
 Student ID Number:    -- Help  Birthdate:  //   MM/DD/YYYY
 Year/Quarter:    Help  Social Security Number: -- Optional
 
Street Address:   Apt. # 
 City: State:  Zip: 
 Email:   Cell:   Home: 
 Previous Name(s):  
   Male           Female    
 
  I refuse or am unable to provide my SSN/ITIN at this time. Initials:________________
 DISCLOSURE STATEMENT: To comply with federal laws, we are required to ask for your Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN). If you do not submit your SSN/ITIN, you will not be denied access to the college; however, you may be subject to civil penalties (refer to Internal Revenue Service Treasury Regulation 1.6050S-1 (e)(4) for more information) of a $50 fine in the event of an audit. If you choose not to provide your SSN/ITIN please check the “I refuse...“ box above and write your initials on the line provided.
A. Services are available for students who have special needs due to a disability. Would you like our SSD staff to contact you with more information?    Yes           No 
B.  High School Attended  State/Country  Years attended   to: 
      Graduated?  Yes  No
 Last college, voc/tech, university attended  State/Country  Years attended   to: 
      Graduated?  Yes  No
C. Are you a U.S. Citizen?    Yes No    If you are not a US citizen, you must indicate what your status is.
  Immigrant/Permanent resident (IM) When was your Permanent Resident card issued? 
  Refugee/Parolee/Conditional Entrant (RF) When was your Alien Number issued? 
  Visa holder; My visa type is: 
        If your visa type is B, F, J, M, or TN, you must go to the International Student Services Office for admission.        
        If your visa type is A, E, G, H, I, K, L, or R, the Enrollment Services Office will admit you.
  Other (please explain): 
 
D.  Class registration – Description          Item number Start Date End Date Price
E.  Which race(s) do you consider yourself to be? (Optional) (Mark up to two boxes)
  Alaska Native   Cambodian   Indonesian   Samoan
  American Indian   Chinese   Japanese   Taiwanese
  Arabian   Eskimo   Korean   Thai
  Asian – Indian   Fijian   Nepali   Tlingit
  Asian – Other   Filipino   Pacific Islander – Other   Vietnamese
  Black or African American   Hawaiian – Native   Pakistani   White
  Other Race: 
  ** If American Indian, please list name of enrolled or principal tribe: 
 -----------------------------------------------------------------------------------------------------------------------------------------------------
 Are you of Spanish/Hispanic origin? (Optional) (Please mark only one box)
  No, (not Spanish/Hispanic)   Yes, Mexican, Mexican-Am., Chicano   Yes, Spanish
  Yes, Central American   Yes, Puerto Rican  
  Yes, Cuban   Yes, South American   
  Yes, other Spanish/Hispanic: 
F.  How long do you plan to attend Edmonds Community College?
  One quarter   Up to two years, no degree planned
  Two quarters   Long enough to complete a degree
  One year   Don’t know
 What is your current work status while attending college?
  Full-time homemaker   Part-time on campus
  Full-time employment (including self and military)   Not employed, but seeking employment
  Part-time off-campus   Not employed, not seeking employment
 What is your prior level of education at entry to Edmonds Community College?
  Less than high school graduation   Certificate (less than two years)
  GED   Associate degree
  High school graduate   Bachelor’s degree or above
  Some post high school, but no degree or certificate
 What was your family status when you started at Edmonds Community College? Were you...
  a single parent with children or other dependents in your care
  a couple with children or other dependents in your care
  without children or other dependents in your care
G.  Note: If you wish to take college classes that are not part of the BTC/WATR program, you will need to complete a new college admission application.
 I herby certify under penalty of perjury under the laws of the state of Washington RCW 9A.72.085 that to the best of my knowledge, all statements on this form are true and correct.
 
 
 
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