Previous or Maiden Name:
UA Student ID#
Gender:
Male
Female
COURSE REGISTRATION 1
FULL LEGAL NAME
(Last)
(First)
Spring
(M.I.)
Mailing Address
State
Zip
Daytime Phone
Fall
Year
0 400
2012
College of Education Professional and Continuing Education (P.A.C.E.)
Email: ETHNIC ORIGIN Ethnic origin is requested for compliance with Title IV of the Civil Rights Act of 1964. Used for statistical purpose only.
Alaskan-Aleut Alaskan Eskimo - Inupiat Alaskan Eskimo - Other Alaskan Eskimo - Yupik Alaskan Indian - Athabascan Alaskan Indian - Southeast Alaskan Indian - Other Alaskan Native - Tsimpsian Alaskan Native - Other American Indian Asian - Pacific Islander Black - Non -Hispanic Hispanic White - Non-Hispanic Other
CRN
Summer
3
Home Phone
City
AA AQ AE AY AT AS AI AM AN IN PI BL HI WH OT
2
Subject Course Section
Improving the educational experience of Alaska's children... High School:
Birthdate:
Diploma
GED
_______ Month
_______ Day
Foreign Equivalent
3211 Providence Drive, PSB 221 Anchorage, AK 99508-8295
_______ Year
Phone: 786-1934
Did not graduate
Email:
[email protected]
Name of High School or GED Test Center: _______________________________ City: _________________ State: _____ H.S./GED Grad. Date: Mo/Yr ________ Veteran Military Code: ADA Active Duty - Army ADAF Active Duty - Air Force ADCG Active Duty - Coast Guard ADM Active Duty - Marine ADN Active Duty - Navy ADNG Active Duty - National Guard ADO Active Duty - Other ADDC Dependent Child
Date(s)
Residency: Resident
Active Military
Non-Resident
Citizenship: US Other If other, please list: _______________________ Foreign Student VISA Type: F1 Permanent Resident Days
UAA OFFICE USE ONLY
What is your goal at UAA? A Associate Degree B Baccalaureate Degree C Certificate G Graduate Program H High School Completion M Maintain License/ Certification J Job Change/Improvement P Personal Development O Other
Date Entered:_____________________________ Initials: _________________________________
UAA ACCOUNTING ONLY Date: _____________ By: __________________ Batch No: _______________________________
Other
Course Title
Credits Graded
Credit REFUND Fees See separtate student information sheet for refund schedule.
41172
555
106 1/27/2012 - 2/11/2012 F
SU
Response to Instruction (RTI): Building 1.0 Student Success 2012
A-F $ 109
Student Signature
X ______________________________________________________________________________ Date: _________________________
TOTAL $
**WE CAN NO LONGER ACCEPT FAXED CREDIT CARD PAYMENTS** Please make checks payable to UAA. TYPE of PAYMENT: Check #____________________ Cash: $_____________________ Card Type( cirlce one : | Visa P A Y M E N T
YOUR SAFETY
Your safety and security are very important to us at UAA. For information about our crime prevention programs, crime reporting procedures, and a three year campus security report, contact the UAA Police Department at 907-786-1120
| MasterCard
PRINT Cardholder Name:________________________________________________ Card Number:_______________________________________________ Expiration: Mo._________ Yr.__________ Signature: ( required for credit card charges): _________________________________________________________________________________________ Date: _____________________________________ CVV # ___________ (3-digit security code on back of card) BILLING STREET ADDRESS: ____________________________________________________________ BILLING ZIP: __________________________ 3rd Party Purchase Order Number: ____________________________________OrganizationName: _______________________________________________________________________________________ Payments
Contact Name: _______________________________________________________________________________________________ Phone: ____________________________________________
