Registration Form
Fresno State ID_______________________ OR Social Security Number
_________________
Date of Birth_______________________
Country of Citizenship:_________________________ (for tax deduction/credit purposes)
If a U.S. citizen, or permanent resident check one: U.S. Citizen Naturalized Refugee/Asylum Immigrant 1-551 (Green Card)
If a Non-Immigrant Visa Holder, check one: F-Visa (student) H1 Visa J Visa TN Visa Other Visa____________________
Last Name First Name Middle Name
Print any other name(s) you have used at California State University, Fresno
Mailing Address Apt. No. City/State/Zip
Email Address Daytime Phone (with area code) Other Phone (with area code)
In case of class cancellation, please notify me by: Email Phone _______________________________
Do you have a bachelor’s degree? Yes No
Professional License/Certicate Number (Required for CEUs) Type of CEU Requested (Required for CEUs)
Male Female
If making payment online or at cashiers, please make sure your payment is receipted as a Continuing and Global Ed payment.
• Check/Money Order (Check# _________________) made payable to Fresno State. Write your Fresno State ID on your check or money order. Return
payment with this form to: Continuing and Global Education, 5005 N. Maple Avenue M/S ED76, Fresno, CA 93740-8025.
• Credit card payments: The University cannot accept credit card information in printed form, whether it is by mail or fax, due to the liability involved with the
sensitive information that is requested. If you wish to pay using a credit card, you have two options:
• go to https://my.fresnostate.edu. Select Student Self Service > Student Center > Account Inquiry. You may pay using American Express, MasterCard,
Visa, or Discover cards ONLY. Please note that a service fee of 2.75% is charged when you pay online with a credit card. However, you may pay by
electronic check online with no service fee.
• go to the Cashier’s Windows, Joyal Building, between 8 am and 4:30 pm, Monday through Friday. You may pay using MasterCard and Visa ONLY.
• CASH PAYMENTS ARE NOT ACCEPTED IN THE CONTINUING AND GLOBAL EDUCATION OFFICE
Signature______________________________________________ Date__________________
Total Fees $
I have read and understand the Continuing and Global Education policies regarding registration and program changes/withdrawals/refunds.
I understand that enrolling in Continuing and Global Education courses does not constitute admission to the University.
Payment Information
Grading Option
Letter CR/NC
Class
Number
Course Title
Class
Dates
# of
Units
Instructor Name
Fee
I certify under penalty of perjury under the laws of the State of California and the United States of America that I have provided complete and accurate responses to all the items. I authorize
California State University to release any information submitted by me to any person, rm, corporation, association, or government agency to verify or explain the information I have provided, to
obtain other information necessary for use by California State University concerning my enrollment or any application I have submitted or may submit for admission, administration of nancial
aid, and/or related to perjury proceedings. My signature certies the accuracy and completeness of the information that I have provided and I understand that a misrepresentation or any omission
may be cause for denial or cancellation of admission, transfer credit, or enrollment. I agree to advise California State University Fresno in writing of any change/s regarding my citizenship and/or
U.S. residency, as long as I am a student at this institution.
Fall 20____
Winter Intersession 20____
Spring 20____
May-June Intersession 20____
Summer 20____
Kremen Education Building, Room 130
559.278.0333
www.fresnostate.edu/cge
Permission #
Additional Course Fees (if any)
(See Program Changes/Withdrawals/Refund Policy, etc. on Reverse Side)
Register online for most credit courses.
Visit www.fresnostate.edu/cge/registration
(please print clearly in black or blue ink)
Course
(e.g. HS 302)
CREDIT COURSES ONLY
TB-12/16
77251
77252
click to sign
signature
click to edit
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