Program Evening ESL Term : Fall 1 Fall 2 Spring 1 Spring 2 Summer ........ Year : __________
Full legal name: Last First Middle Former or Maiden
Sex: Male Female
CU student number _____________________ (if applicable) Social Security No: _______________________(Required for TRA tax credits.)
Birthdate: (month)________(day)__________(year)________ Age: ___________
Home Work Address (No. and Street, Apt. No.)
Address Line 2
City, State Zip+4
If using "Work" address, enter COMPANY NAME:
Home Phone Day Phone E-mail :
Citizenship:
U.S. Citizen
Alien Registration # ___________________
Non-U.S. Citizen - temporary status:
Country: ___________________
Immigration Type: ______________
Ethnicity:
African American or Black, not of Hispanic origin
American Indian or Alaskan Native - Tribe: _________________________________________
American Indian or Alaskan Native, Non-Tribe member
Asian or Pacific Islander
Hispanic, Chicano, Mexican American, Latino
Multiracial - define: ________________________________________
White, not of Hispanic origin
I do not wish to provide this information
Certification: I certify that I am registered with the Selective Service.
I am not required to register with the Selective Service because:
I am a female.
I am in the U.S. Armed Forces: active duty
I have not yet reached my 18th birthday.
I am age 26, or older, by the first day of class
I am a non-immigrant alien lawfully admitted in the U.S.
1. Have you served, or are you now serving on active duty with the U.S. Armed Forces? No Yes, From: _______________ To: _____________
2. Are you a University of Colorado faculty/staff member? No Yes
3. Have you ever enrolled in courses at any campus of the University of Colorado? No Yes,
If yes, most recent: Term: _____ Year: _____ Campus: __________
4. Do you have a pending criminal charge OR have you ever been convicted of a crime, made a plea of guilty, accepted a deferred judgment, been adjudicated , or been required to register as a sex offender? (Misdemeanor traffic offenses are exempt.) No Yes, If yes, you must attach the required "CE supplemental form."
5. Have you ever been placed on probations, suspended, expelled or been subject to official disciplinary action from any high school or postsecondary institution ofor any academic misconduct or behavioral misconduct? No Yes
$
675.00
Course (Tuesday & Thursday)
355.00
Total Enclosed $
I hereby certify that, to the best of my knowledge, the information furnished on this application is true and complete. Please register me for the course(s) listed above. I agree to observe all campus policies and regulations including the University Honor Code. ......04/2007
Student's Signature: ____________________________________________________
Date:________________
Return to the Registration page