Extended Education Registration Form

For your security, we no longer have a submittable registration form. 
Internet and email registration will not be accepted.
Please fill out this form, print it, and enroll by fax, mail or phone at the numbers and address below:

Extended Education
1801 E. Cotati Ave.
Rohnert Park, CA. 94928
tel: (707) 664 2394
fax:(707) 664-2613

* indicates required field

*Term you wish to enroll in:
*Social Security#
*Date of Birth
Sex (enter M or F)
*Name

last

first middle

 
*Current Mailing Address
*City
*State
*Zip
*Day Phone (xxx xxx-xxxx)
Evening Phone (xxx xxx-xxxx)
*Email address


*Class level or degree held

*Have you ever enrolled at SSU before ? YES NO

If Graduate, degree held Date earned

*Where did you learn about this course?

Occupation:

Other

Ethnic Code: Your voluntary response to this question is requested so that we may comply with the
Federal Civil Rights Act of 1964 and the California Title IX Education Amendment.

Courses you wish to enroll in

*Course Title *Dept. & Course #
(e.g. BUS 200)		 *Class #
(0000)		 *Units *Fee
 

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

*Signature for policies

VISA MasterCard Discover American Express

*For the amount of $

*Card Holder's Name

*Credit Card Number *Exp. Date

*Signature for Credit Card (only necessary if mailing or faxing)

*Date

If you are mailing or faxing in this form please sign above (if using a credit card) or attach your check or money order to the form if mailing it in.

Mail to:
Extended Education Registration, Sonoma State University
1801 E. Cotati Avenue
Rohnert Park, CA 94928-3609
or FAX to: (707) 664-2613 after completing the bankcard information.