MA Spanish Registration Form (Spring and Fall Only)

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)

Semester for which you are registering

Student ID#

Name: *

Address: *

City: *

State: *

Zip code: *

E-mail: *

Day Phone: *

Evening Phone:

Sex

Male
Female

Birthdate:

mm/dd/yyyy

Have you ever been enrolled at SSU before?

yes
no

Occupation

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

	Course	Dept & Course #	Class #	Units	Fee
	Practicum/Internship - Form 2 (SPAN 501 requires Form 2 contract to be submitted and signed.)	SPAN 501	4344	4	$1560
Elective Course Approval - Form 1 (Each SPAN 595 selected below requires one Form 1 submittal. ) Please indicate topic for each SPAN 595 Special Study below (e.g.: "Topics in Linguistic Anthropology", etc.)
	Special Studies	SPAN 595		1	$ 390
	Special Studies	SPAN 595		2	$ 780
	Special Studies	SPAN 595		3	$1170
	Special Studies	SPAN 595		4	$1560
	Special Studies	SPAN 595		( )
	Special Studies	SPAN 595		( )
				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:

Sonoma State University School of Extended Education