Open University Registration Form

OPEN UNIVERSITY REGISTRATION

Dept & Course
[Ex: LIBS800]

Approval Signature

Dept. Chair Signature
(Nat.Science Lab only)

Print, obtain instructor's signature, then deliver (or mail or fax) to:
SSU Extended Education Registration Stevenson Hall 1012 1801 E. Cotati. Ave. Rohnert Park, CA 94928
Tel: (707) 664-2394 Fax: (707) 664-2613

Name:
Address:
City/State/Zip:
Day Phone:
Night Phone:
Social Security #:
Date of Birth:
Gender	Male Female
Ethnic Code:
Class Level
Have you ever been enrolled at SSU before?	Yes No
Occupation:	If Other, describe:
Will your tuition be reimbursed by your employer?	Yes No If yes, employer name:
Where did you learn about this course?	If Other, describe:

Courses Requested:

I agree to abide by the deadlines and policies governing these courses. If my payment by check is not honored by the bank, I am still responsible for all course fees.

Signature:

I enclose check/money order/VISA/MasterCard for:

Credit Card Number:

Expiration Date:

Cardholder's name:

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

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

n which subject area(s) are you most interestd in taking courses?

How did you find out about Open University enrollment?

Indicate the highest level of education you have completed

Who is paying for your course(s)?

Indicate your age group

Have you enrolled in open university prior to this semester?

yes no

What is your residency status?

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

yes no

Which category best describes your employment status?

Name of employer (optional):

Your position title (optional):

For Office Use Only:

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