Banner ID Number: ______________________________________________________
or Social Security Number: ________________________________________________
Last Name: _____________________________________________________________
First Name: ____________________________________ M.I. _____________________
Home Address: __________________________________________________________
City: _________________________________ State: ___________ Zip: _____________
Daytime Phone (including area code): _________________
Cell Phone: ______________________
Email Address: ____________________________________
List the course you would like to register for below:
Course # &
Fax completed form to the Office of Registration and Records at (585) 395-5392
Mail completed form to the Office of Registration and Records, The College at Brockport, 350 New Campus Drive, Brockport, NY, 14420-2966.
Please call the Office of Registration and Records at (585) 395-2531 to confirm receipt of your form.
New-to-the College students must submit The College at Brockport New Student Information Form to the Office of Special Sessions & Programs before your registration can be processed.