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Continuing Education Registration Form

Please read these instructions carefully before completing this form.
Fields that are required to submit this form successfully are denoted with a red asterisks (*).

Before you submit this form, be certain that you have entered all of the required information. If you fail to submit a required field you will receive an error message. If you receive an error,please use the back button on your browser to return to this form and try again.
NOTE: This is NOT an interactive registration system. You will be contacted if there are any problems with your registration.

 PERSONAL INFORMATION


Social Security Number*
or Student ID*
Last Name*
First Name*, M.I.
Email Address*
Legal Address*
City, State, Zip*
Home Phone* () -
Business Phone () -
Date of Birth (MM/DD/YY)
Sex Male Female
Senior Citizen (60 or older) Yes     No

COURSE SELECTION


Course
Number
Section
Number
Course Title Day/Days
Class meets
Time of Day
Class meets
Fees
Example: ARTS:733 601 Pottery:  Beginning T 6:30-9:30pm 85

 ADDITIONAL INFORMATION


If you have any additional information regarding your registration, please enter it here

 PAYMENT AND CREDIT CARD INFORMATION


Total cost for courses:*
(You must total the fees for each class and enter that information here. If zero, no charge card information is necessary.)

Credit Card:* Visa

visa.jpeg (5153 bytes)
MasterCard

mc.jpeg (5572 bytes)
Discover/Novus

discover.jpeg (5778 bytes)
debit.gif (344 bytes)
Visa MC

Card Number:* - --
Expiration Date:*
(enter as mm/yy)
/


Complete only if name or address on credit card is different than name and address of student.

Name (as it appears on Credit Card):
Street Addresss:
City
State:
Zip Code:

 


Before you submit this form, be certain that you have entered all of the required information. If you fail to submit a required field you will receive an error message. If you receive an error, please use the back button on your browser to return to this form and try again.

The following fields are required before you may successfully submit this form:

 



In the event that you receive an error when submitting this form, please use the back button on your browser to return to this screen to complete the required fields.