B.A. Liberal Studies Napa Registration Form - Fall

OFFICE USE ONLY:

Verified by:	Cash Receipt#:	Check #
Payee Name	VISA/MC authorization #	Total Paid $:
By	Date

DO NOT EMAIL THIS FORM - IT WILL NOT BE ACCEPTED OR PROCESSED.

Fill in, print (using print button at the bottom of this form), then mail or fax to: SSU Extended Education, 1801 E. Cotati Ave., Rohnert Park, CA. 94928

Permanent Residence:
(Check appropriate box)

Sonoma (0049)
Lake (0017)
Napa (0028)
Solano (0048)

Other
State (6000)
If not USA (7000)

Student ID#

Name: *

Address: *

City: *

State: *

Zip code: *

E-mail: *

Day Phone: *

Evening Phone:

Will your employer reimburse your tuition?

yes
no

If yes, Company name:

Company Address: city, state, zip

Have you ever been enrolled at SSU before?

yes
no

Occupation

Title of Course(s) you wish to enroll in:

Course	Dept & Course # (e.g. SPAN 500)	Class #	Units	Fee
Latina/o Humanisms	CALS 451	4229	4	$1400
Biology of Cancer	BIOL 309	4235	3	$1050
Portfolio Evaluation	SSCI 400	4263	3	$1050
Internship	SSCI 499	4264	1	$ 350
Internship	SSCI 499	4265	2	$ 700
Internship	SSCI 499	4266	3	$1050

		Total		$

I have applied for financial aid:

yes
no

If yes, you must complete and sign an Authorization to Apply Financial Aid to Other Charges form and return it to the Registrar in Extended Education, Stevenson 1012.

I enclose:

Check
Money Order
VISA

MasterCard
Discover
American Express

Signature *

Date Signed: *

Cardholder's name *

Card # *

Exp. Date *

Mail to: School of Extended Education, Sonoma State University, 1801 E. Cotati Ave., Rohnert Park, CA 94928-3609.

$ Amount enclosed: *

Sonoma State University School of Extended Education

B.A. Liberal Studies Napa Registration Form - Fall