Not for Open University


Registration Form Student ID# (if applicable) Email address Company Name Title Daytime telephone (include area code) Last Name Address—Number and Street City State Enter here any other name which you have used at CSUSM


I am registering for the following courses: Course Number


Zip Code First Name Date of Birth (month-day-year) Fax (include area code) Evening telephone (include area code) M.I. Social Security Number


(Necessary to create CSUSM student ID and for tax credit statement)


Date


Are you a current CSUSM student? ❏ Yes ❏ No


Term you are registering for: ❏ Spring ❏ Summer ❏ Fall


Year:______________


Units


Course Title


Course Dates


Instructor Signature (if required)


MUST BE COMPLETED


❏ Extended Learning Catalog ❏ Friend/Relative ❏ Recruited by Instructor ❏ News Story in Paper/TV ❏ Email


This section must be completed to process your registration. How you heard about the program/course, check one option only:


❏ Search Engine (like Google) ❏ Company Referral ❏ Internet (EL Web site) ❏ Direct Mail ❏ Advertisement


❏ Referred by Campus/Other Department of the School


❏ Other


CASHIER ONLY


I have read the course catalog, I understand and agree to abide by the deadlines and policies governing these courses, and I accept full academic and financial responsibility for each class granted.


Signature:_________________________________________________________________Date:___________________ Total Fees


Payment by: ❏ Check or Money Order


IMPORTANT Make checks payable to CSUSM. ❏ Agency/Company to be billed (Must attach PO or appropriate documentation) ❏ Master Card


❏ Visa ❏ Discover ❏ American Express


Card Number:_______________________________________________________________Exp. Date:__________________Security Code:______________ Print Cardholder’s Name:___________________________________________ Cardholder’s Signature:____________________________________________


Mail to: CSUSM Extended Learning 333 S. Twin Oaks Valley Road San Marcos, CA 92096


Phone: (760) 750-4020 (800) 500-9377


# (PLEASE PRINT CLEARLY)


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