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Continuing Education Registration Form

ALL FIELDS MUST BE COMPLETED BEFORE SUBMITTING

Personal Information
Full Name (First, Middle, Last):
Address:
City, State, Zip
,
Home Phone:
Email Address:

All Students: This information is requested for compliance with U.S. government statistical reporting requirements. Ethnicity/Race (check one):

African American
Hispanic              
White
American Indian or Alaskan Native         
Non-resident Alien          
Two or more Races          
Unknown

Academic Registration
Campus:
AGTS Main (Springfield, Mo.)    NCAL     Valley Forge
Semester:
Summer 2014    Fall 2014
Course Letters Course Number Course Title Instructor Audit? Directed Research?
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N

Financial Registration

Payment Options: Check all that apply. Payment is due on or before first day of class or course start date. 

Full Payment      Deferred Payment Plan*    Private Loan    Federal Loan
  
Scholarships/Tuition Discounts**         AGWM (00 Account)       Credit Card (Visa, MC, Discover)***

*A  $50 deferred payment fee will be added to your account if you choose the deferred payment option.

**To apply for a tuition discount, download and print the Tuition Discount Application and fax the completed and signed form to the AGTS Business Office, (417-268-1001). This form is required at least two weeks prior to the start of class. A new form is required each semester.

*** If paying by credit card, complete the following:

 

Credit Card Number:

Expiration Month:

Expiration Year:

Card Security Code:   What is the card security code?

Name as it appears on credit card:

 

By signing and then submitting this form, I understand and agree to the following provisions:

  1. I will pay all charges and fees for the course(s) indicated on this registration form by the due date(s) listed (see Payment Options above).
  2. This promissory note is legal and binding contract between AGTS and me. I will pay all attorney and collection costs necessary for the collection of any amount not paid when due. I understand these collection/attorney fees will be an additional 40% of the unpaid balance. In the event that a delinquent balance on my AGTS account is forwarded to a third-party collection agency,  I authorize AGTS to disclose to the agency any personal information in my academic records necessary for the collection of past due balances.
  3. If paying my outstanding bill with a loan, I will complete and file all financial aid paperwork by the financial aid deadline. If I miss the deadline, my account will be assessed a $50 deferred payment fee and I will be required to pay one-third of outstanding balance on or before first day of class.
  4. If I no longer meet the qualifications of a loan, tuition discount, institutional scholarship or any other type of financial aid, I am responsible for the unpaid balance.
  5. If I do not fulfill the conditions of this promissory note, I will not be allowed to attend further classes until the balance is paid in full.
  6. My account will be charged a $25 late fee per month for payments not made on time.
  7. I am responsible to inform AGTS of any change in my address.

Electronic Signature (type your name as you would sign it):

 

Updated: Monday, June 30, 2014 2:26 PM

 
1.800.467.AGTS • 1.800.467.2487 • Fax: 417.268.1001 • agts@agts.edu1435 N. Glenstone Ave., Springfield, Mo. 65802
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