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Application for Special Credit Registry for edX Courses

Personal Information

First Name

Middle Initial

Last Name

Maiden Name

Date of Birth

Email Used for edX Course(s)

Residence Address

Address Line 1
(Number & Street)

Address Line 2
(Apt, Unit, etc.)

City

State

Zip Code

Mailing Address (if different)

Address Line 1
(Number & Street)

Address Line 2
(Apt, Unit, etc.)

City

State

Zip Code

More Information

Telephone - Home

Telephone - Cell

Other Email (Home)

Other Email (Work)

Are you a resident of Connecticut?

YesNo

Are you a U.S. Citizen?

YesNo

Specific edX Courses Completed

Specific edX Courses Completed (LIST ALL)

E-Signature

I hereby certify that the above statements are true and correct to the best of my knowledge. I hereby make application for credit registry at Charter Oak State College subject to the policies and procedures of the College.

Type your full name as your signature