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

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

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09/13
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
University Extension Registration Form
Non-Credit
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_________________________________________________ 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
Payment Method
❒
Check/Money Order. Make check payable to CSUDH Extension
❒
I authorize the use of my VISA/MC/Discover (circle one)
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
Non Credit Registration Layout
Course Fee $________________
Late Fee $________________
Total Fee Submitted $________________
Reg. No.
Section
Term
Course Title
Non
Credit
Fee
Course No.
Subject
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California State University, Dominguez Hills University Extension Registration (California State University, Dominguez Hills)

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Completed 18 August 2020

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