Application for Special Credit Registry for edX CoursesHomeedXApplication for Special Credit Registry for edX CoursesPersonal InformationFirst NameMiddle InitialLast NameMaiden NameDate of Birth * / / ( mm / dd / yyyy )Email Used for edX Course(s)Residence AddressAddress Line 1(Number & Street)Address Line 2(Apt, Unit, etc.)CityStateZip CodeMailing Address (if different)Address Line 1(Number & Street)Address Line 2(Apt, Unit, etc.)CityStateZip CodeMore InformationTelephone - HomeTelephone - CellOther Email (Home)Other Email (Work)Are you a resident of Connecticut?YesNoAre you a U.S. Citizen?YesNoSpecific edX Courses CompletedSpecific edX Courses Completed (LIST ALL)E-SignatureI 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 signatureSubmit ApplicationFacebook icon ShareTwitter icon ShareGoogle+ icon ShareLinkedIn icon Share
