Course Registration Form

Please complete this form; print, sign it,
and send it to:
California State University, Hayward
Extended & Continuing Education
25800 Carlos Bee Blvd
Hayward CA 94542-3012
OR Call: Bay Area, (510) 885-3605
Call: Outside Bay Area, 1-800-730-2784
Fax: (510) 885-4817

Please have your Visa or MasterCard ready when calling.

Name Social Security #: - -
Address 1 Date of Birth
Address 2 Sex: Male Female
City State Zip Code
Day Phone Ext : Evening Phone Ext :
Please sign and date this form to verify for official University
records that the above information is correct.
Signature: ________________________________________ Date: ______-______-________
Ethnic Origin:(Select one only)

Quarter: Year :

Please check ONE
I would like to register for the class with WITH tapes. - $400
HIST 3414-HA
I would like to register for the class WITHOUT buying the tapes - $312
HIST 3414-HB

Please makes checks payable to CSUH

Visa/MasterCard #: - - - - Expiration Date:
PRINT Cardholder Name:

Signature: __________________________________________________
** Full payment must accompany this form.
For Office Use Invoice Cash Ck/MO: