Open University Registration Form

Fill in, print, obtain instructor's signature, then mail or fax to: SSU Extended Education, 1801 E. Cotati Ave., Rohnert Park, CA. 94928. (Fax: 707-664-2613)

Term to which you are applying*

Name:*

Address:*

Date of Birth

Gender:

female male

Use of Social Security Number:

Sonoma State University uses the social security number as the identifier for student records maintained in your association with the campus and, if needed, to help collect debts owed the university. Applicants are required to include their social security number in designated places on applications for admission pursuant to authority contained in Title 5, California Code of Regulations, Section 41201.

SS#: (no hyphens please)*

E-mail:*

Day Phone:*

Evening Phone:

City:*

State:*

Zip code:*

Class level or degree held:

If Graduate, degree held:

Date degree earned:

- Month - Day Year

Enrolled at SSU before?

Yes No

Where did you learn about this course(s)?

Will your tuition be reimbursed by your employer?

yes no

If yes, name of employer:

Occupation

If profession not listed:

Ethnic Code:

COURSE #1:

Class #		Dept./Nbr (e.g. BUS800)	Units	Fee

Instructor Approval Signature:*

Dept. Chair Signature

COURSE #2:

Class #	Dept/Nbr (e.g. BUS800)		Units	Fee

Instructor Approval Signature:

Dept. Chair Signature

COURSE #3:

Class #	Dept/Nbr (e.g. BUS800)	Units	Fee

Instructor Approval Signature:

Dept. Chair Signature

I agree to abide by the deadlines and policies governing these courses and am responsible for all course fees.*

Check if agree

Credit Card Type:*

Visa Mastercard Discover American Express

I enclose check/money order/credit card for this amount:*

Cardholder's Name:*

Credit Card Number:*

Date of Card Expiration:*

- Month - Day Year

Signature for Credit Card (print, then sign here)

Date of Signature*

- Month - Day Year

Mark the single most important reason why you have enrolled in Open University:

Which of the reasons listed below best explains why you are taking college courses? (mark all that apply)

To earn credits toward a degree Professional development: to improve my job skills Personal development: to gain new knowledge To meet new people Other

In which subject area(s) are you most interested in taking courses?

Arts & Humanities Business & Economics Social Sciences Natural Sciences Education

How did you find out about Open University enrollment?

Who is paying for your course(s)?

Age group:

Have you enrolled in Open University prior to this semester?

yes no

Residency Status:

Do you plan to apply for admission to the University to work toward a degree?

yes no

Which category describes your employment status:

Name of employer:

Your position title:

Print this form, then sign in "signature for credit card" box. If faxing, you may fax the printed form. Fax number: (707) 664-2613. If mailing, without using credit card, please attach check or money order to this printed form, and mail to:

Verified by:	Cash:	Check:
Payee:	Visa/MC:	Authorization to bill:
Total Pid:	By:	Date:

SSU Extended Education 1801 E. Cotati Ave. Rohnert Park, CA. 94928.

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Sonoma State University

Open University Registration Form

Classes for which you would like to enroll:

For Office Use Only