B.A. Liberal Studies Napa Registration Form

This form is ONLY for mail or fax. Fill in, print, 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	4241	4	$1400
Civil Liberties and the Constitution	CCJS 489	4242	4	$1400
The Human Environment	ENPS 301	4240	3	$1050
Intro to Portfolio	SSCI 300	4243	1	$ 350
Portfolio Evaluation	SSCI 400	4244	3	$1050
Internship	SSCI 499	4245	1	$ 350
Internship	SSCI 499	4246	2	$ 700
Internship	SSCI 499	4247	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 the Fee Voucher Promissory Note and return them both to the Registrar in Extended Education, Stevenson 1012.

I enclose:

Check
Money Order
VISA

MasterCard
Discover
American Express

Cardholder's name *

Card # *

Exp. Date *

Signature *

Date Signed: *

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

$ Amount enclosed: *

OFFICE USE ONLY: