Fillable California State University, Dominguez Hills Open University Registration (California State University, Dominguez Hills)

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California State University, Dominguez Hills Open University Registration (California State University, Dominguez Hills)

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For more information, call the College of Extended & International Education, (310) 243-3741 or visit the website: www.csudh.edu/ee
California State University, Dominguez Hills
Open University Registration Form
Date of Application_____________________Student ID:___________________________________Birthdate____________________________
month/day/year
Social Security Number____________________________ Declined to State
❒
Reason_____________________________________________
Name
Last First Middle Initial
Address
Street City State Zip
Telephone
Day Evening Cell Phone
New address? yes
❒
no
❒
Gender: male
❒
female
❒
Have you been enrolled at CSUDH before? yes
❒
no
❒
Date last enrolled_______________________________________________________
Employer_________________________________________________Personal Email __________________________________________________
Company Name
What level of education have you completed?
❒
Some High School
❒
High School Graduate
❒
Some College
❒
AA/AS Degree
❒
BA/BA Degree
❒
Graduate Degree
Course Information
Course Fee $________________
Late Fee $________________
Total Fee Submitted $________________
Payment Method
❒
❒
Account Number
Exp Date
3 Digit Security No.
Cardholder's Name
Cardholder's Signature
Refund Policy
Refunds are granted in accordance with the State refund schedule. Refunds are not automatic; you must file appropriate forms in the Extended
Education Office in order to receive a refund. Refunds take a minimum of six to eight weeks for processing. To receive a refund of fees for a non-
credit class or a class offering continuing education, extension credit or professional units, you must notify Extended Education between the
hours of 8:00am and 8:00pm Monday through Thursday, from 8:00am to 5pm on Fridays and from 8:00am to 1:30pm on Saturdays, at least two
working days before the course begins. You will be asked to send a written request for a refund to our office.
4 WAYS TO REGISTER
By PHONE: You may register by
phone with your VISA, Discover or
MasterCard by calling (310) 243-
3741.
Mail to CSU Dominguez Hills,
Extended Education,
EE 1100, 1000 East Victoria Street
Carson, CA 90747
Stop by the College of Extended & International Education on Campus
1000 East Victoria Street, Carson, CA.
Online: my.csudh.edu
I authorize the use of my VISA/MC/Discover (circle one) on
Open University Layout
There is a non-refundable 2.75% convenience fee ($3 minimum) charged by our third party processor for paying with a credit card.
Debit cards are treated the same as credit cards and will incur the service fee. There is no fee charged if you pay by check or money
order. If you are paying by e-check please register and pay online at my.csudh.edu
Check/Money Order. Make check payable to CSUDH Extension
Course No.
Department
Units
Fee
Course Title
Instructor Signature
Section
Term
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California State University, Dominguez Hills Open University Registration (California State University, Dominguez Hills)

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Completed 18 August 2020

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